1801268255 NPI number — IORA HEALTH ILLINOIS PHYSICIANS, P.C.

Table of content: (NPI 1801268255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801268255 NPI number — IORA HEALTH ILLINOIS PHYSICIANS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IORA HEALTH ILLINOIS PHYSICIANS, P.C.
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:
1801268255
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 TREMONT ST FL 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02108-5004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-454-4672
Provider Business Mailing Address Fax Number:
617-701-7740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
611 W ROOSEVELT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60607-4911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-570-3382
Provider Business Practice Location Address Fax Number:
773-453-8116
Provider Enumeration Date:
10/26/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MUNK
Authorized Official First Name:
MARC-DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
617-454-4672

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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