1356347264 NPI number — DR. HENRY C ECHIVERRI MD

Table of content: DR. HENRY C ECHIVERRI MD (NPI 1356347264)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356347264 NPI number — DR. HENRY C ECHIVERRI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ECHIVERRI
Provider First Name:
HENRY
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356347264
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3S 517 WINFIELD RD
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
WARRENVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60555-3159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-836-9121
Provider Business Mailing Address Fax Number:
630-836-9126

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3S 517 WINFIELD RD
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
WARRENVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60555-3159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-836-9121
Provider Business Practice Location Address Fax Number:
630-836-9126
Provider Enumeration Date:
06/24/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084V0102X , with the licence number:  036075202 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: 036075202 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036075202 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036075202 . This is a "STATE LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".