Organization
DAVENPORT MEDICAL INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TRACEY DAVENPORT MD (PRESIDENT/AUTHORIZED OFFICIAL)
(773) 543-8964
Entity
Organization
Contact information
Practice address
1023 MAPLETON AVE, OAK PARK, IL 60302-1405
(773) 543-8964
Mailing address
1023 MAPLETON AVE, OAK PARK, IL 60302-1405
(773) 543-8964
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036114303
—
IL
Enumeration date
07/28/2022
Last updated
07/28/2022
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