1265606131 NPI number — MR. ALEXIS BERTUMEN NAVARES PHYSICIAN ASSISTANT

Table of content: MR. ALEXIS BERTUMEN NAVARES PHYSICIAN ASSISTANT (NPI 1265606131)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265606131 NPI number — MR. ALEXIS BERTUMEN NAVARES PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NAVARES
Provider First Name:
ALEXIS
Provider Middle Name:
BERTUMEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
M

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:
1265606131
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2400 MICHAEL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ZION
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-917-9197
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
655 ROCKLAND RD
Provider Second Line Business Practice Location Address:
STE 206
Provider Business Practice Location Address City Name:
LAKE BLUFF
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-283-0720
Provider Business Practice Location Address Fax Number:
847-283-0723
Provider Enumeration Date:
04/22/2008

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: 363A00000X , with the licence number:  238000160 , 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)





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