Basic Information
| Provider Information | |||||||||
| NPI: | 1144425794 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HENRY T PIMENTEL MDSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5501 W 79TH ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | BURBANK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604591784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738844523 | ||||||||
| FaxNumber: | 7738844580 | ||||||||
| Practice Location | |||||||||
| Address1: | 326 W 64TH ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606213114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739623900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2007 | ||||||||
| LastUpdateDate: | 12/05/2014 | ||||||||
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| AuthorizedOfficialLastName: | PIMENTAL | ||||||||
| AuthorizedOfficialFirstName: | HENRY | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7736519200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 036041603 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036041603 | 05 | IL | MEDICAID | 215344 | 01 | IL | MEDICARE PTAN | OTHER | 21623403 | 01 | IL | BLUE SHIELD | OTHER |