1053814814 NPI number — CHICAGO FUNCTIONAL NEUROLOGY GROUP, LTD.

Table of content: (NPI 1053814814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053814814 NPI number — CHICAGO FUNCTIONAL NEUROLOGY GROUP, LTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHICAGO FUNCTIONAL NEUROLOGY GROUP, 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:
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:
1053814814
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 N US HIGHWAY 12 STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRING GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60081-8308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-675-0675
Provider Business Mailing Address Fax Number:
815-675-9836

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 S MICHIGAN AVE STE 302
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60603-3225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-767-3500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/17/2018

Additional Information

Authorized Official

Authorized Official Last Name:
DESTEPHANO
Authorized Official First Name:
RALPH
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER/CHIROPRACTIC NEUROLOGIST
Authorized Official Telephone Number:
312-767-3500

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  038007206 , 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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