Basic Information
| Provider Information | |||||||||
| NPI: | 1538379516 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HUMBERTO VERGARA MD & ASSOCIATES SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1431 N WESTERN AVE | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606221797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732784811 | ||||||||
| FaxNumber: | 7732785920 | ||||||||
| Practice Location | |||||||||
| Address1: | 1431 N WESTERN AVE | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606221797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732784811 | ||||||||
| FaxNumber: | 7732785920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 08/31/2010 | ||||||||
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| AuthorizedOfficialLastName: | VERGARA | ||||||||
| AuthorizedOfficialFirstName: | HUMBERTO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7732784811 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | 036-072013 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
No ID Information.