Basic Information
Provider Information | |||||||||
NPI: | 1447513338 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEVY | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: | BONIQUIT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 WESTBROOK CORPORATE CTR | ||||||||
Address2: | STE 240 | ||||||||
City: | WESTCHESTER | ||||||||
State: | IL | ||||||||
PostalCode: | 601545701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7082362600 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2450 WOLF RD | ||||||||
Address2: | STE F | ||||||||
City: | WESTCHESTER | ||||||||
State: | IL | ||||||||
PostalCode: | 601545643 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7082362673 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2012 | ||||||||
LastUpdateDate: | 02/25/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 125061401 | IL | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080S0010X | 036141341 | IL | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Sports Medicine |
No ID Information.