1144229865 NPI number — DAVID R EDELSTEIN MD SC

Table of content: (NPI 1144229865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144229865 NPI number — DAVID R EDELSTEIN MD SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID R EDELSTEIN MD SC
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:
1144229865
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 N MICHIGAN AVE
Provider Second Line Business Mailing Address:
SUITE 501
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60602-3402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-332-3699
Provider Business Mailing Address Fax Number:
312-332-3698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1917 WESTLEIGH DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENVIEW
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60025-7612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-332-3699
Provider Business Practice Location Address Fax Number:
312-332-3698
Provider Enumeration Date:
07/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
EDELSTEIN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
312-332-3699

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  036-047656 , 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: 21606223 . This is a "BLUE CROSS OF ILLINOIS" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com