Basic Information
| Provider Information | |||||||||
| NPI: | 1922501725 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 418 S. 38TH AVE | ||||||||
| Address2: | APT #53 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528367590 | ||||||||
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| Practice Location | |||||||||
| Address1: | 251 E HURON ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129262000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2018 | ||||||||
| LastUpdateDate: | 05/16/2018 | ||||||||
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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 | 390200000X | IL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 125.071864 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | 125.071864 | IL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.