1134115231 NPI number — ALEJANDRA PEREZ-TAMAYO MD

Table of content: ALEJANDRA PEREZ-TAMAYO MD (NPI 1134115231)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134115231 NPI number — ALEJANDRA PEREZ-TAMAYO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEREZ-TAMAYO
Provider First Name:
ALEJANDRA
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:
1134115231
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
840 S WOOD ST # MC958
Provider Second Line Business Mailing Address:
SUITE 618
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60612-4325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-355-0104
Provider Business Mailing Address Fax Number:
312-355-3764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 W TAYLOR ST
Provider Second Line Business Practice Location Address:
3F-OCC
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-4795
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-996-6883
Provider Business Practice Location Address Fax Number:
312-413-1206
Provider Enumeration Date:
09/23/2005

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: 208600000X , with the licence number:  036065562 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0122X , with the licence number: 036065562 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086X0206X , with the licence number: 036065562 , 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: 036065562 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00129722 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 21622027 . This is a "BCBS PROVIDER ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 020052881 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 202351 . This is a "BCBS PROVIDER ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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