1942802517 NPI number — MEGAN FAVIA PHYSICIAN ASSISTANT

Table of content: MEGAN FAVIA PHYSICIAN ASSISTANT (NPI 1942802517)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942802517 NPI number — MEGAN FAVIA PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAVIA
Provider First Name:
MEGAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
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:
1942802517
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12059 ARLENE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOMER GLEN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60491-6813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-846-5459
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4400 W 95TH ST STE 408
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK LAWN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60453-2662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-346-4055
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/09/2020

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: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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