1982688891 NPI number — COLE DAVID LUNDQUIST MD

Table of content: COLE DAVID LUNDQUIST MD (NPI 1982688891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982688891 NPI number — COLE DAVID LUNDQUIST MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUNDQUIST
Provider First Name:
COLE
Provider Middle Name:
DAVID
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1982688891
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7447 W. TALCOTT AVE
Provider Second Line Business Mailing Address:
SUITE 321
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60631
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-774-7122
Provider Business Mailing Address Fax Number:
773-631-7642

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1875 W DEMPSTER ST
Provider Second Line Business Practice Location Address:
STE 660
Provider Business Practice Location Address City Name:
PARK RIDGE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60068-1186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-698-1210
Provider Business Practice Location Address Fax Number:
847-698-0475
Provider Enumeration Date:
12/05/2005

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: 207N00000X , with the licence number:  036056878 , 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: 036056878 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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