Basic Information
| Provider Information | |||||||||
| NPI: | 1598203523 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHAFFER | ||||||||
| FirstName: | KEN | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCHAFFER | ||||||||
| OtherFirstName: | KEN | ||||||||
| OtherMiddleName: | J. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 29373 NETWORK PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606731293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473905900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1775 DEMPSTER ST | ||||||||
| Address2: | |||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600681143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477232210 | ||||||||
| FaxNumber: | 8476963394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2017 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 209015091 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.