1568413821 NPI number — WAUKEGAN TERRACE

Table of content: DR. ROBERT ROY VAUGHAN DDS (NPI 1295807881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568413821 NPI number — WAUKEGAN TERRACE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAUKEGAN TERRACE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1568413821
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5151 CHURCH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SKOKIE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60077-1123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-933-9200
Provider Business Mailing Address Fax Number:
847-674-5794

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
919 WASHINGTON PARK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUKEGAN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60085-7258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-623-9100
Provider Business Practice Location Address Fax Number:
847-623-9179
Provider Enumeration Date:
05/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WEINFELD
Authorized Official First Name:
AVRUM
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
847-674-5795

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  0027052 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 310500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 363109618 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0054304 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".