1578648408 NPI number — ELISABETH AV DESAPEREIRA,MD,LTD

Table of content: (NPI 1578648408)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578648408 NPI number — ELISABETH AV DESAPEREIRA,MD,LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELISABETH AV DESAPEREIRA,MD,LTD
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:
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:
1578648408
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3018 PARKSIDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIGHLAND PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60035-1067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-433-0057
Provider Business Mailing Address Fax Number:
847-432-2174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1117 S MILWAUKEE AVE
Provider Second Line Business Practice Location Address:
SUITE B8
Provider Business Practice Location Address City Name:
LIBERTYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60048-3798
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-281-9990
Provider Business Practice Location Address Fax Number:
847-295-0293
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DESAPEREIRA
Authorized Official First Name:
ELISABETH
Authorized Official Middle Name:
A V
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
847-389-5930

Provider Taxonomy Codes

  • Taxonomy code: 2084P0804X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036049974 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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