Basic Information
Provider Information | |||||||||
NPI: | 1912920265 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEDDABURNE | ||||||||
FirstName: | CLAUDIA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4343 N CLARENDON AVE | ||||||||
Address2: | APT 1902 | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606132698 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7738712457 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | RESURRECTION IMMEDIATE CARE CENTER | ||||||||
Address2: | 7230 W. NORTH AVE STE 106 B | ||||||||
City: | ELMWOOD PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 607074262 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7084533000 | ||||||||
FaxNumber: | 7084534660 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2006 | ||||||||
LastUpdateDate: | 04/29/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036069378 | IL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 036069378 | 05 | IL |   | MEDICAID | 1620469 | 01 | IL | BCBS GROUP NUMBER | OTHER | 1619414 | 01 | IL | BCBS GROUP | OTHER |