1164552154 NPI number — GEORGEANN L IACONO RUSSELL PH.D

Table of content: GEORGEANN L IACONO RUSSELL PH.D (NPI 1164552154)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164552154 NPI number — GEORGEANN L IACONO RUSSELL PH.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IACONO RUSSELL
Provider First Name:
GEORGEANN
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D
Provider Gender Code:
F

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:
1164552154
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1825 DE FOREST LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HANOVER PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60133-5905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-837-8028
Provider Business Mailing Address Fax Number:
708-763-2120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7411 WEST LAKE STREET
Provider Second Line Business Practice Location Address:
BUILDING A, SUITE L120
Provider Business Practice Location Address City Name:
RIVER FOREST
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60305-1876
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-488-1919
Provider Business Practice Location Address Fax Number:
708-763-2120
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  071-004593 , 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: 21623162 . This is a "BCBS GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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