1154498533 NPI number — ONDREJ CHUDOBA, M.D., S.C.

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 1154498533 NPI number — ONDREJ CHUDOBA, M.D., S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ONDREJ CHUDOBA, M.D., S.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:
1154498533
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11317 SMITH DR
Provider Second Line Business Mailing Address:
11924 OAK CREEK PARKWAY
Provider Business Mailing Address City Name:
HUNTLEY
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60142-9602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-515-8131
Provider Business Mailing Address Fax Number:
847-515-8142

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11317 SMITH DR
Provider Second Line Business Practice Location Address:
11924 OAK CREEK PARKWAY
Provider Business Practice Location Address City Name:
HUNTLEY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60142-9602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-515-8131
Provider Business Practice Location Address Fax Number:
847-515-8142
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHUDOBA
Authorized Official First Name:
ONDREJ
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
630-415-3087

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , 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: 1627496 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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