Provider Demographics
NPI:1679617872
Name:PASSEN, EDWARD (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:PASSEN
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:PO BOX 1447
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-7447
Mailing Address - Country:US
Mailing Address - Phone:847-823-9800
Mailing Address - Fax:847-823-9801
Practice Address - Street 1:1775 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068
Practice Address - Country:US
Practice Address - Phone:847-823-9800
Practice Address - Fax:847-823-9801
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360661332085R0202X, 2085U0001X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036066133Medicaid
IL01627348OtherBCBS
IL598650Medicare ID - Type Unspecified
IL036066133Medicaid