Basic Information
| Provider Information | |||||||||
| NPI: | 1104883735 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHADWICK | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 N EDWARD ST | ||||||||
| Address2: | GSBLL | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625264163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178762868 | ||||||||
| FaxNumber: | 2178762874 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 W MCKINLEY AVE | ||||||||
| Address2: | ENTA ALLERGY, HEAD & NECK INSTITUTE | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178763682 | ||||||||
| FaxNumber: | 2178763345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 08/20/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 036058535 | IL | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 036058535 | 05 | IL | MEDICAID |