Basic Information
| Provider Information | |||||||||
| NPI: | 1588663876 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANTOS | ||||||||
| FirstName: | RENE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4647 LINCOLN HWY | ||||||||
| Address2: | |||||||||
| City: | MATTESON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604432319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087475850 | ||||||||
| FaxNumber: | 7087479991 | ||||||||
| Practice Location | |||||||||
| Address1: | 71 W 156TH ST | ||||||||
| Address2: | SUITE 305 | ||||||||
| City: | HARVEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604264260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083333113 | ||||||||
| FaxNumber: | 7083338991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 11/25/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 036070775 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 036070775 | 05 | IL | MEDICAID | 3160176976 | 01 | IL | BLUE SHIELD | OTHER |