1114542347 NPI number — OLGA BREZDEN

Table of content: OLGA BREZDEN (NPI 1114542347)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114542347 NPI number — OLGA BREZDEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREZDEN
Provider First Name:
OLGA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1114542347
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2868 N BROADWAY 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:
60657-6017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-569-3525
Provider Business Mailing Address Fax Number:
872-206-8120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2868 N BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60657-6017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-569-3525
Provider Business Practice Location Address Fax Number:
872-206-8120
Provider Enumeration Date:
06/12/2020

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: 363LF0000X , with the licence number:  209021535 , 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: 209021535 . This is a "IDFPR" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".