Provider Demographics
NPI:1861624421
Name:EDWARD V GHISLANDI, M.D.PC
Entity type:Organization
Organization Name:EDWARD V GHISLANDI, M.D.PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAUCHAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-282-2520
Mailing Address - Street 1:5641 W IRVING PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-2742
Mailing Address - Country:US
Mailing Address - Phone:773-282-2520
Mailing Address - Fax:773-282-7970
Practice Address - Street 1:5641 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-2742
Practice Address - Country:US
Practice Address - Phone:773-282-2520
Practice Address - Fax:773-282-7970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-17
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036039002Medicaid
IL036039002Medicaid