Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | 125.074341 | IL |
NPI | 1043772627 |
---|---|
Provider Name | Ryan Char Kelm |
First Address | Chicago, IL 60612-3844 |
Second Address | Chicago, IL 60612 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/04/2019 |
Last Update Date | 30/07/2020 |