Basic Information
| Provider Information | |||||||||
| NPI: | 1639295025 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VILLA | ||||||||
| FirstName: | EUGENE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29373 NETWORK PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606731293 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3134 N CLARK ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606574414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737664949 | ||||||||
| FaxNumber: | 3127664909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 036093194 | IL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 036093194 | 05 | IL | MEDICAID |