1861728677 NPI number — REDIET KOKEBIE MD

Table of content: REDIET KOKEBIE MD (NPI 1861728677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861728677 NPI number — REDIET KOKEBIE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOKEBIE
Provider First Name:
REDIET
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1861728677
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2525 S MICHIGAN AVE
Provider Second Line Business Mailing Address:
B-522
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60616-2333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-567-2000
Provider Business Mailing Address Fax Number:
312-567-6156

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2525 S MICHIGAN AVE
Provider Second Line Business Practice Location Address:
FAMILY HEALTH CENTER
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60616-2333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-567-2000
Provider Business Practice Location Address Fax Number:
312-567-6156
Provider Enumeration Date:
10/29/2009

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: 207RR0500X , with the licence number:  036116844 , 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: 01621679 . This is a "BSBCIL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 950150 . This is a "MEDICARE GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036116844 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 336085525 . This is a "CCS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".