1114116522 NPI number — RAVENSWOOD HEALTH CENTER, P.C.

Table of content: (NPI 1114116522)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114116522 NPI number — RAVENSWOOD HEALTH CENTER, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAVENSWOOD HEALTH CENTER, P.C.
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:
1114116522
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4256 N. RAVENSWOOD AVE,
Provider Second Line Business Mailing Address:
SUITE NUMBER 101
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-327-2225
Provider Business Mailing Address Fax Number:
773-327-7554

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4256 N. RAVENSWOOD AVE.
Provider Second Line Business Practice Location Address:
SUITE NUMBER 101
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-327-2225
Provider Business Practice Location Address Fax Number:
773-327-7554
Provider Enumeration Date:
10/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FENNEMA
Authorized Official First Name:
JASON
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
773-327-2225

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  038-008864 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 070009516 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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