1891739355 NPI number — DR. GEORGE MICHAEL PROCENTO M.D.

Table of content: DR. GEORGE MICHAEL PROCENTO M.D. (NPI 1891739355)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891739355 NPI number — DR. GEORGE MICHAEL PROCENTO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROCENTO
Provider First Name:
GEORGE
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1891739355
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
755 S MILWAUKEE AVE
Provider Second Line Business Mailing Address:
SUITE 240
Provider Business Mailing Address City Name:
LIBERTYVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60048-3253
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-918-9179
Provider Business Mailing Address Fax Number:
847-918-9635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
755 S MILWAUKEE AVE
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
LIBERTYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60048-3253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-918-9179
Provider Business Practice Location Address Fax Number:
847-918-9635
Provider Enumeration Date:
06/15/2006

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: 207Q00000X , 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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