1033348206 NPI number — FAYCOR N A INC

Table of content: (NPI 1033348206)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033348206 NPI number — FAYCOR N A INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAYCOR N A INC
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:
1033348206
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2535 GREENVIEW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60062-7031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-291-9058
Provider Business Mailing Address Fax Number:
847-291-9095

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4700 N MARINE DR
Provider Second Line Business Practice Location Address:
5TH FLOOR
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60640-5120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-291-9058
Provider Business Practice Location Address Fax Number:
847-291-9095
Provider Enumeration Date:
07/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
FEINSTEIN
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
847-291-9058

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  036064248 , 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: 036064248 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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