1497792840 NPI number — EDM CONSULTANT SERVICES LTD

Table of content: (NPI 1497792840)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497792840 NPI number — EDM CONSULTANT SERVICES LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDM CONSULTANT SERVICES 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:
RIM JOUBRAN
Provider Other Organization Name Type Code:
5
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:
1497792840
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
675 W NORTH AVE
Provider Second Line Business Mailing Address:
STE 104
Provider Business Mailing Address City Name:
MELROSE PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-681-7695
Provider Business Mailing Address Fax Number:
708-345-7112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
675 W NORTH AVE
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
MELROSE PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-681-7695
Provider Business Practice Location Address Fax Number:
708-345-7112
Provider Enumeration Date:
06/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOUBRAN
Authorized Official First Name:
RIM
Authorized Official Middle Name:
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
708-681-7695

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  36091925 , 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: 3362078002 . This is a "CIGNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036091925 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 21623287 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".