1356462030 NPI number — MS. VENITA ROCHELLE FLUCKER PA-C

Table of content: MS. VENITA ROCHELLE FLUCKER PA-C (NPI 1356462030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356462030 NPI number — MS. VENITA ROCHELLE FLUCKER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLUCKER
Provider First Name:
VENITA
Provider Middle Name:
ROCHELLE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FLUCKER PA-C
Provider Other First Name:
VENITA
Provider Other Middle Name:
R.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1356462030
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8127 S LOOMIS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60620-3859
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-994-9203
Provider Business Mailing Address Fax Number:
312-864-5921

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8127 S LOOMIS BLVD
Provider Second Line Business Practice Location Address:
1900 W.POLK SUITE 500
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60620-3859
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-864-5900
Provider Business Practice Location Address Fax Number:
312-864-9579
Provider Enumeration Date:
04/02/2007

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: 282N00000X , with the licence number:  85001970 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 085-001970 , 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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