Basic Information
Provider Information | |||||||||
NPI: | 1902010903 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SANTOS | ||||||||
FirstName: | ERIC | ||||||||
MiddleName: | EUGENE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 809059 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606809059 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8888438475 | ||||||||
FaxNumber: | 3148496395 | ||||||||
Practice Location | |||||||||
Address1: | 600 E 1ST ST | ||||||||
Address2: | ST MARGARET'S HOSPITAL/DEPARTMENT OF PATHOLOGY | ||||||||
City: | SPRING VALLEY | ||||||||
State: | IL | ||||||||
PostalCode: | 613621512 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8156641470 | ||||||||
FaxNumber: | 8156641141 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/09/2007 | ||||||||
LastUpdateDate: | 05/02/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 036.117681 | IL | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
ID | Type | State | Issuer | Description | 14D0431111 | 01 | IL | CLIA | OTHER | 036.117681 | 01 | IL | IL STATE LICENSE NUMBER | OTHER | 215550 | 01 | IL | MEDICARE GROUP NUMBER | OTHER | 1114110780 | 01 | IL | GROUP NPI | OTHER | 615604 | 01 | IL | BSCHI | OTHER |