1114178217 NPI number — FABIO ORTEGA MD SC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114178217 NPI number — FABIO ORTEGA MD SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FABIO ORTEGA MD SC
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:
FABIO ORTEGA MD SC
Provider Other Organization Name Type Code:
3
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:
1114178217
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9933 LAWLER AVE
Provider Second Line Business Mailing Address:
SUITE 409
Provider Business Mailing Address City Name:
SKOKIE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60077
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-679-3200
Provider Business Mailing Address Fax Number:
847-679-4631

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9933 LAWLER AVE
Provider Second Line Business Practice Location Address:
SUITE 409
Provider Business Practice Location Address City Name:
SKOKIE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-679-3200
Provider Business Practice Location Address Fax Number:
847-679-4631
Provider Enumeration Date:
10/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ORTEGA
Authorized Official First Name:
FABIO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
847-679-3200

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  336029781 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207V00000X , with the licence number: 036065413 , 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)

  • Identifier: 036065413 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 31601691 . This is a "BCBS OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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