Basic Information
| Provider Information | |||||||||
| NPI: | 1942309547 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEO TAIBERG, MD SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 OAKMONT LN | ||||||||
| Address2: | SUITE 1600 | ||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605595511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307892550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2525 S MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606162333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307892550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 01/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | TAIBERG | ||||||||
| AuthorizedOfficialFirstName: | LEO | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOLE PROPRIETOR | ||||||||
| AuthorizedOfficialTelephone: | 6307892550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01634713 | 01 | IL | BCBS PROVIDER ID | OTHER | DC3900 | 01 | IL | RAIL ROAD MEDICARE | OTHER |