Provider Demographics
NPI:1053436931
Name:TYSON, C (MD)
Entity type:Individual
Prefix:
First Name:C
Middle Name:
Last Name:TYSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8012 S CRANDON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-1124
Mailing Address - Country:US
Mailing Address - Phone:773-734-1117
Mailing Address - Fax:
Practice Address - Street 1:8012 S CRANDON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-1124
Practice Address - Country:US
Practice Address - Phone:773-734-1117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD16687Medicare UPIN
IL767480Medicare PIN
ILL27545Medicare PIN