1235538653 NPI number — STEFANIE EL-DARAZI DPT

Table of content: STEFANIE EL-DARAZI DPT (NPI 1235538653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235538653 NPI number — STEFANIE EL-DARAZI DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EL-DARAZI
Provider First Name:
STEFANIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
METKA
Provider Other First Name:
STEFANIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235538653
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-296-2222
Provider Business Mailing Address Fax Number:
630-759-6106

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1224 MILLER PKWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53214-3614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-847-2971
Provider Business Practice Location Address Fax Number:
414-645-8025
Provider Enumeration Date:
08/21/2014

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: 225100000X , with the licence number:  12839-24 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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