1710931555 NPI number — ENDOCRINE CARE LLC

Table of content: (NPI 1710931555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710931555 NPI number — ENDOCRINE CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENDOCRINE CARE LLC
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:
1710931555
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1090
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATTESON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60443-4090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-747-5850
Provider Business Mailing Address Fax Number:
708-747-9991

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6703 159TH ST
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
TINLEY PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60477-1781
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-532-6490
Provider Business Practice Location Address Fax Number:
708-532-6262
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DE BUSTROS
Authorized Official First Name:
ANDREE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
M.D./SOLE PROPRIETOR
Authorized Official Telephone Number:
708-532-6490

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  036-081805 , 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: 0001636300 . This is a "BCBSIL GROUP #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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