1770703407 NPI number — AMY L PANOKA PT

Table of content: AMY L PANOKA PT (NPI 1770703407)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770703407 NPI number — AMY L PANOKA PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PANOKA
Provider First Name:
AMY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUDNICK
Provider Other First Name:
AMY
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770703407
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 W WACKER DR
Provider Second Line Business Mailing Address:
SUITE 1020
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60606-1216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-640-0329
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 E HURON ST
Provider Second Line Business Practice Location Address:
SUITE 901
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60611-2999
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-640-1112
Provider Business Practice Location Address Fax Number:
312-640-1011
Provider Enumeration Date:
04/26/2007

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: 225100000X , with the licence number:  070013248 , 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: 1619980 . This is a "BCBS OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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