1215053517 NPI number — FABIO ORTEGA M.D.

Table of content: FABIO ORTEGA M.D. (NPI 1215053517)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215053517 NPI number — FABIO ORTEGA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ORTEGA
Provider First Name:
FABIO
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1215053517
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2650 RIDGE AVE ROOM 1223
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SKOKIE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60077-1057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-570-2040
Provider Business Mailing Address Fax Number:
847-733-5315

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6810 N. MCCORMICK BLVD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLNWOOD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-933-1773
Provider Business Practice Location Address Fax Number:
847-679-1505
Provider Enumeration Date:
03/21/2007

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: 207V00000X , with the licence number:  036065413 , 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: 036065413 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com