Basic Information
Provider Information | |||||||||
NPI: | 1982625034 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FERNANDO HERNANDEZ, M.D., S.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1730 PARK ST | ||||||||
Address2: | SUITE 10 | ||||||||
City: | NAPERVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 605632688 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6307180200 | ||||||||
FaxNumber: | 6307180900 | ||||||||
Practice Location | |||||||||
Address1: | 1725 W HARRISON ST | ||||||||
Address2: | SUITE 843 | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606123841 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3129422356 | ||||||||
FaxNumber: | 3129425313 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/22/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
AuthorizedOfficialFirstName: | FERNANDO | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN / OWNER | ||||||||
AuthorizedOfficialTelephone: | 6307180200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 31601998 | 01 | IL | BLUE CROSS / BLUE SHIELD | OTHER |