1770687030 NPI number — MR. JOHN MARTIN RAINE L.C.P.C.

Table of content: MR. JOHN MARTIN RAINE L.C.P.C. (NPI 1770687030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770687030 NPI number — MR. JOHN MARTIN RAINE L.C.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAINE
Provider First Name:
JOHN
Provider Middle Name:
MARTIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
L.C.P.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RAINE-OKUBO
Provider Other First Name:
JOHN
Provider Other Middle Name:
MARTIN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
L.C.P.C.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1770687030
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2430 GREENFIELD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENVIEW
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60025-4870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-724-5233
Provider Business Mailing Address Fax Number:
847-724-5260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ADVOCATE HEALTH CENTER SPECIALTY 4
Provider Second Line Business Practice Location Address:
2545 S. DR. M. L. KING DRIVE
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-808-4589
Provider Business Practice Location Address Fax Number:
312-842-7859
Provider Enumeration Date:
09/08/2006

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: 101YP2500X , 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: 0001625669 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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