1740257484 NPI number — TREVOR J SLOM MD

Table of content: TREVOR J SLOM MD (NPI 1740257484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740257484 NPI number — TREVOR J SLOM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SLOM
Provider First Name:
TREVOR
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1740257484
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
880 W. CENTRAL RD.
Provider Second Line Business Mailing Address:
SUITE 8100
Provider Business Mailing Address City Name:
ARLINGTON HEIGHTS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-255-5030
Provider Business Mailing Address Fax Number:
847-255-0156

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
880 W. CENTRAL RD.
Provider Second Line Business Practice Location Address:
SUITE 8100
Provider Business Practice Location Address City Name:
ARLINGTON HEIGHTS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-255-5030
Provider Business Practice Location Address Fax Number:
847-255-0156
Provider Enumeration Date:
03/01/2006

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: 207RI0200X , with the licence number:  036-095393 , 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: 0001636111 . This is a "BLUE CROSS BLUE SHIELD OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 205454606 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036095393 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 615318700 . This is a "US DEPT OF LABOR - 2222 DIVISION, CHICAGO LOCATION" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 615318701 . This is a "US DEPT OF LABOR-2001 CALIFORNIA, CHICAGO LOCATION" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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