1255528535 NPI number — DANA P PERES EDELSON M.D., MS

Table of content: DANA P PERES EDELSON M.D., MS (NPI 1255528535)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255528535 NPI number — DANA P PERES EDELSON M.D., MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERES EDELSON
Provider First Name:
DANA
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D., MS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EDELSON
Provider Other First Name:
DANA
Provider Other Middle Name:
P
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D., MS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1255528535
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
180 HARVESTER DR
Provider Second Line Business Mailing Address:
SUITE 110, MC 1099
Provider Business Mailing Address City Name:
BURR RIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60527-7594
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-834-4740
Provider Business Mailing Address Fax Number:
773-834-0946

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5841 S MARYLAND AVE
Provider Second Line Business Practice Location Address:
MC 5000, W312
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60637-1447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-834-2191
Provider Business Practice Location Address Fax Number:
773-834-2238
Provider Enumeration Date:
10/01/2007

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: 207R00000X , with the licence number:  036111499 , 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: 036111499 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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