1215251541 NPI number — JOHN V. WHITE, MD, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215251541 NPI number — JOHN V. WHITE, MD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN V. WHITE, MD, LLC
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:
1215251541
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
04/05/2010
NPI Reactivation Date:
12/01/2010

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8816 W DEMPSTER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NILES
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60714-5109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-518-1762
Provider Business Mailing Address Fax Number:
847-723-3007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8816 W DEMPSTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NILES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60714-5109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-518-1762
Provider Business Practice Location Address Fax Number:
847-723-3007
Provider Enumeration Date:
03/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
RYJEWSKI
Authorized Official First Name:
CONSTANCE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
847-518-1762

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , with the licence number:  036067291 , 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: 036067291 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0001632574 . This is a "BLUECROSS/BLUESHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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