1417549098 NPI number — ALEX ZACHARY STOLLER MS, RDN

Table of content: ALEX ZACHARY STOLLER MS, RDN (NPI 1417549098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417549098 NPI number — ALEX ZACHARY STOLLER MS, RDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STOLLER
Provider First Name:
ALEX
Provider Middle Name:
ZACHARY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, RDN
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:
1417549098
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 W LAKE COOK RD STE 160
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUFFALO GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60089-2091
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-632-1880
Provider Business Mailing Address Fax Number:
847-520-6095

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 W LAKE COOK RD STE 160
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUFFALO GROVE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60089-2091
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-632-1880
Provider Business Practice Location Address Fax Number:
847-520-6095
Provider Enumeration Date:
02/05/2021

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: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 164008317 . This is a "STATE LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".