| NPI |
1477518462 |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
| Entity Type Code |
1 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
| Provider Last Name Legal Name |
CONWAY |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
| Provider First Name |
DANIEL |
The first name of the provider, if the provider
is an individual. |
| Provider Middle Name |
ROBERT |
The first name of the provider, if the provider
is an individual. |
| Provider Credential Text |
M.D. |
The abbreviations for professional degrees or credentials used or held by the provider,
if the provider is an individual. Examples
are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations
will not be verified by NPS. |
| Provider First Line Business Practice Location Address |
880 W CENTRAL RD STE 3800 |
The abbreviations for professional degrees or credentials used or held by the provider,
if the provider is an individual. Examples
are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations
will not be verified by NPS. |
| Provider Business Practice Location Address City Name |
ARLINGTON HEIGHTS |
The city name in the location address of the provider being identified. |
| Provider Business Practice Location Address State Name |
IL |
The city name in the location address of the provider being identified. |
| Provider Business Practice Location Address Postal Code |
600052369 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
| Provider Business Practice Location Address Country Code If outside U S |
US |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
| Provider Business Practice Location Address Telephone Number |
8474839800 |
The telephone number associated with the location address of the provider being identified. |
| Provider Business Practice Location Address Fax Number |
8474839808 |
The telephone number associated with the location address of the provider being identified. |
| Provider Enumeration Date |
4/20/2006 |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Last Update Date |
4/28/2021 |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Provider Gender Code |
M |
The code designating the provider’s gender if the provider is a person. |
| Healthcare Provider Taxonomy Code 1 |
208600000X |
The code designating the provider’s gender if the provider is a person. |
| Provider License Number 1 |
036074858 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
| Provider License Number State Code 1 |
IL |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
| Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
| Other Provider Identifier 1 |
036074858 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 1 |
05 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 1 |
IL |
|
| Is Sole Proprietor |
N |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
| NPI Certification Date |
4/28/2021 |
|