Basic Information
| Provider Information | |||||||||
| NPI: | 1780883660 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEPHAN | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | Q | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7447 W TALCOTT AVE | ||||||||
| Address2: | STE 182 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606313712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737925155 | ||||||||
| FaxNumber: | 7735947975 | ||||||||
| Practice Location | |||||||||
| Address1: | 7447 W TALCOTT AVE | ||||||||
| Address2: | STE 182 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606313712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737925155 | ||||||||
| FaxNumber: | 7735947975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2007 | ||||||||
| LastUpdateDate: | 12/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/18/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036117889 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 400280 | 01 | IL | GROUP PTAN | OTHER | 821050 | 01 | IL | GROUP PTAN | OTHER |