1437492675 NPI number — NICOLE M. GLADCHENKO PA-C

Table of content: NICOLE M. GLADCHENKO PA-C (NPI 1437492675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437492675 NPI number — NICOLE M. GLADCHENKO PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLADCHENKO
Provider First Name:
NICOLE
Provider Middle Name:
M.
Provider Name Prefix Text:
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:
EVERT
Provider Other First Name:
NICOLE
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1437492675
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 734240
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:
60673-4240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-744-8554
Provider Business Mailing Address Fax Number:
630-495-1770

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 W HIGGINS RD STE 1040
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOFFMAN ESTATES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60169-2049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-884-8096
Provider Business Practice Location Address Fax Number:
847-490-0978
Provider Enumeration Date:
04/05/2013

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:  3101-23 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 085.007852 , 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: 1437492675 . This is a "BCBSWI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1437492675 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1437492675 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2630 . This is a "MERCYCARE INSURANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: K400452296 . This is a "WI MEDICICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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