1831287887 NPI number — DR. NORMITA MADAMBA LICUDINE MD

Table of content: DR. NORMITA MADAMBA LICUDINE MD (NPI 1831287887)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831287887 NPI number — DR. NORMITA MADAMBA LICUDINE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LICUDINE
Provider First Name:
NORMITA
Provider Middle Name:
MADAMBA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1831287887
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7049 N KILPATRICK AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLNWOOD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-677-7264
Provider Business Mailing Address Fax Number:
773-379-4034

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4758 WEST WASHINGTON BLVD
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:
60644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-379-4348
Provider Business Practice Location Address Fax Number:
773-379-4034
Provider Enumeration Date:
10/11/2006

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: 207Q00000X , with the licence number:  036051696 , 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: 036051696 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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