1336702125 NPI number — EDGAR AUF DEM GRABEN

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336702125 NPI number — EDGAR AUF DEM GRABEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AUF DEM GRABEN
Provider First Name:
EDGAR
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1336702125
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6493 N NORTHWEST HWY APT 409
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:
60631-1892
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-774-4946
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 N RIVER RD STE G122
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DES PLAINES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60016-1209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-581-0800
Provider Business Practice Location Address Fax Number:
847-410-4910
Provider Enumeration Date:
04/17/2019

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: 1835G0303X , with the licence number:  054-035924 , 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: 054-035924 . This is a "ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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