1902987076 NPI number — DR. STAVROS NICHOLAS MALTEZOS M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902987076 NPI number — DR. STAVROS NICHOLAS MALTEZOS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALTEZOS
Provider First Name:
STAVROS
Provider Middle Name:
NICHOLAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1902987076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPT 2299 PAYSPHERE CIRCLE
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:
60674
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-725-9890
Provider Business Mailing Address Fax Number:
630-725-0988

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3825 HIGHLAND AVE
Provider Second Line Business Practice Location Address:
TOWER 1, SUITE 5M
Provider Business Practice Location Address City Name:
DOWNERS GROVE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60515-1552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-725-9890
Provider Business Practice Location Address Fax Number:
630-725-0988
Provider Enumeration Date:
10/17/2006

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: 207T00000X , 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: 0001617783 . This is a "BLUE SHIELD OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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