1336174291 NPI number — CHICAGO SURGICAL CLINIC, LTD.

Table of content: DR. MICHELLE THERESE MODISETT AU.D. (NPI 1427289289)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336174291 NPI number — CHICAGO SURGICAL CLINIC, LTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHICAGO SURGICAL CLINIC, LTD.
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:
1336174291
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 E STRONG ST
Provider Second Line Business Mailing Address:
SUITE 7
Provider Business Mailing Address City Name:
WHEELING
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60090-2979
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-215-0530
Provider Business Mailing Address Fax Number:
847-215-0951

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 E STRONG ST
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
WHEELING
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60090-2979
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-215-0530
Provider Business Practice Location Address Fax Number:
847-215-0951
Provider Enumeration Date:
07/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEVITIN
Authorized Official First Name:
YELENA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
847-215-0530

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  036097501 , 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: 01628326 . This is a "BC/BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 036097501 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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