Basic Information
| Provider Information | |||||||||
| NPI: | 1396972865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EARY | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | LYNNE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 ERIE CT | ||||||||
| Address2: | SUITE 6160 | ||||||||
| City: | OAK PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 603022566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087631490 | ||||||||
| FaxNumber: | 7087637232 | ||||||||
| Practice Location | |||||||||
| Address1: | 5939 HARRY HINES BLVD STE 303 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753902566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146453900 | ||||||||
| FaxNumber: | 2146453901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2009 | ||||||||
| LastUpdateDate: | 11/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 125056753 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | S2576 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036-130684 | 01 | IL | IL MEDICAL LICENSE | OTHER | 036-130684 | 05 | IL | MEDICAID | S2576 | 01 | TX | TEXAS MEDICAL LICENSE | OTHER |