1194815944 NPI number — DR. LORRAINE D D'ASTA PH.D.

Table of content: DR. LORRAINE D D'ASTA PH.D. (NPI 1194815944)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194815944 NPI number — DR. LORRAINE D D'ASTA PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
D'ASTA
Provider First Name:
LORRAINE
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
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:
1194815944
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 S EDGEWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA GRANGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60525-2149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-655-9040
Provider Business Mailing Address Fax Number:
708-482-0667

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 W CHICAGO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HINSDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60521-3356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-655-9040
Provider Business Practice Location Address Fax Number:
708-482-0667
Provider Enumeration Date:
10/13/2006

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: 103TC0700X , with the licence number:  71-2763 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 103TS0200X , with the licence number: 1163916 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 227-2056 . This is a "BCBS PROVIDER ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".