1235381906 NPI number — ALEKSANDAR KONDIC, INC

Table of content: (NPI 1235381906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235381906 NPI number — ALEKSANDAR KONDIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALEKSANDAR KONDIC, INC
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:
1235381906
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
309 N OLTENDORF RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STREAMWOOD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60107-6889
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-855-5155
Provider Business Mailing Address Fax Number:
630-855-5187

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
309 N OLTENDORF RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STREAMWOOD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60107-6889
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-855-5155
Provider Business Practice Location Address Fax Number:
630-855-5187
Provider Enumeration Date:
10/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSELL
Authorized Official First Name:
CARLA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
630-855-5155

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  036116931 , 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: 036116931 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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