Basic Information
| Provider Information | |||||||||
| NPI: | 1588640924 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RONIN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1775 BALLARD ROAD | ||||||||
| Address2: | |||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473182500 | ||||||||
| FaxNumber: | 8473182558 | ||||||||
| Practice Location | |||||||||
| Address1: | 1775 BALLARD RD | ||||||||
| Address2: | |||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600681005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473182500 | ||||||||
| FaxNumber: | 8473182558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2005 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 036078858 | IL | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 06168781 | 01 | IL | BC/BS | OTHER | P00213724 | 01 | IL | MEDICARE RAILROAD | OTHER | 0360788582 | 05 | IL | MEDICAID |