1407996564 NPI number — AUSENCIO NUNEZ M.D

Table of content: AUSENCIO NUNEZ M.D (NPI 1407996564)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407996564 NPI number — AUSENCIO NUNEZ M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NUNEZ
Provider First Name:
AUSENCIO
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:
1407996564
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1841 W ARMY TRAIL RD
Provider Second Line Business Mailing Address:
R
Provider Business Mailing Address City Name:
ADDISON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60101-1901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-238-9235
Provider Business Mailing Address Fax Number:
630-238-0426

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1841 W ARMY TRAIL RD
Provider Second Line Business Practice Location Address:
R
Provider Business Practice Location Address City Name:
ADDISON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60101-1901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-238-9235
Provider Business Practice Location Address Fax Number:
630-238-0426
Provider Enumeration Date:
02/07/2007

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:  036078267 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 036078267 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036078267 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02205538 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 363950044 . This is a "TAXID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CF9448 . This is a "RAILROAD MEDICARE GROUP #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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