1114086303 NPI number — FJ WALL MD & WILLIAM J RUFF MD

Table of content: (NPI 1114086303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114086303 NPI number — FJ WALL MD & WILLIAM J RUFF MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FJ WALL MD & WILLIAM J RUFF MD
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:
1114086303
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2800 W 87TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60652-3831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7600 W COLLEGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALOS HEIGHTS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60463-1001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-361-8449
Provider Business Practice Location Address Fax Number:
708-361-8469
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUFF
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
708-361-8449

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , 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: 01615630 . This is a "BCBS OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: DE1040 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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