1013190289 NPI number — EDUARDO VILLA, M.D., S.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013190289 NPI number — EDUARDO VILLA, M.D., S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDUARDO VILLA, M.D., S.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1013190289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5471 RFD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60047-8211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-520-4887
Provider Business Mailing Address Fax Number:
847-520-4936

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
622 N MILWAUKEE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROSPECT HEIGHTS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60070-2353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-520-4887
Provider Business Practice Location Address Fax Number:
847-520-4936
Provider Enumeration Date:
12/11/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VILLA
Authorized Official First Name:
EDUARDO
Authorized Official Middle Name:
DE JESUS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
847-520-4887

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  36074074 , 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: NA643303 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".