Basic Information
Provider Information | |||||||||
NPI: | 1629210091 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHEVY CHASE CORP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BRONZEVILLE PARK-OXY | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7257 N LINCOLN AVE | ||||||||
Address2: |   | ||||||||
City: | LINCOLNWOOD | ||||||||
State: | IL | ||||||||
PostalCode: | 607121810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8479332600 | ||||||||
FaxNumber: | 8479330686 | ||||||||
Practice Location | |||||||||
Address1: | 3400 S INDIANA AVE | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606163841 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3128425000 | ||||||||
FaxNumber: | 3128423790 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/01/2009 | ||||||||
LastUpdateDate: | 04/01/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEVITIN | ||||||||
AuthorizedOfficialFirstName: | REUVEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PATIENT ACCOUNTS MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8477456240 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X | 0040592 | IL | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
ID Information
ID | Type | State | Issuer | Description | 1770654907 | 01 |   | NPI IDENTIFIER | OTHER |