Basic Information
Provider Information | |||||||||
NPI: | 1407973183 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PICKERING | ||||||||
FirstName: | PAUL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 180 HARVESTER DR | ||||||||
Address2: | SUITE 110 | ||||||||
City: | BURR RIDGE | ||||||||
State: | IL | ||||||||
PostalCode: | 605275993 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7738341061 | ||||||||
FaxNumber: | 7738340946 | ||||||||
Practice Location | |||||||||
Address1: | 1111 E 87TH ST | ||||||||
Address2: | SUITE 900 | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606197038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7737022900 | ||||||||
FaxNumber: | 7737022277 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2007 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036102715 | IL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 036102715 | 05 | IL |   | MEDICAID |