1265431712 NPI number — DR. ELBIO M. FLORESSTADLER M.D.

Table of content: DR. ELBIO M. FLORESSTADLER M.D. (NPI 1265431712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265431712 NPI number — DR. ELBIO M. FLORESSTADLER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLORESSTADLER
Provider First Name:
ELBIO
Provider Middle Name:
M.
Provider Name Prefix Text:
DR.
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:
1265431712
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 74821
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60694-4821
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-747-5850
Provider Business Mailing Address Fax Number:
708-747-9991

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 INGALLS DR
Provider Second Line Business Practice Location Address:
PATHOLOGY DEPT.
Provider Business Practice Location Address City Name:
HARVEY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60426-3558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-915-5763
Provider Business Practice Location Address Fax Number:
708-915-3786
Provider Enumeration Date:
07/18/2005

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: 207ZP0102X , with the licence number:  036093150 , 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: 036093150 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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