Provider Demographics
NPI:1730173071
Name:STANNARD, ROBERT T (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:T
Last Name:STANNARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5931 W ERIE ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644-1427
Mailing Address - Country:US
Mailing Address - Phone:773-378-6830
Mailing Address - Fax:
Practice Address - Street 1:115 N PARKSIDE AVE
Practice Address - Street 2:CIRCLE FAMILY HEALTHCARE NETWORK
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-3040
Practice Address - Country:US
Practice Address - Phone:773-921-9669
Practice Address - Fax:773-921-2609
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036071500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036071500Medicaid
P12546Medicare ID - Type Unspecified
IL036071500Medicaid