1104052794 NPI number — DR. CHRISTINE A DEFOREST D.O.

Table of content: DR. CHRISTINE A DEFOREST D.O. (NPI 1104052794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104052794 NPI number — DR. CHRISTINE A DEFOREST D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEFOREST
Provider First Name:
CHRISTINE
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1104052794
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3001 N GREEN BAY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60064
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-973-3102
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
51 N 39TH ST
Provider Second Line Business Practice Location Address:
M01 MYRIN BASEMENT
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-588-6915
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2009

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: 207P00000X , with the licence number:  OS023866 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 25MB12688800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: VAD0000 . This is a "EMERGENCY MEDICINE" identifier . This identifiers is of the category "OTHER".




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