1902218209 NPI number — SUPERMAN DAVID BERROW MS, ATC, CES

Table of content: SUPERMAN DAVID BERROW MS, ATC, CES (NPI 1902218209)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902218209 NPI number — SUPERMAN DAVID BERROW MS, ATC, CES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERROW
Provider First Name:
SUPERMAN
Provider Middle Name:
DAVID
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, ATC, CES
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:
1902218209
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2712 W NORTH AVE APT 2F
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60647-5237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-489-7645
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1920 N FOOTBALL DR
Provider Second Line Business Practice Location Address:
HALAS HALL
Provider Business Practice Location Address City Name:
LAKEFOREST
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-528-1234
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/21/2014

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: 174400000X , with the licence number:  096003014 , 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)





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