Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 207W00000X | Ophthalmology | | 036066839 | ILLINOIS | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 200325390 | OTHER | INDIANA | MEDICARE LEGACY PROVIDER NUMBER |
| 2 | 200871680A | OTHER | INDIANA | MEDICAID LOCATION MUNSTER |
| 3 | 180046208 | OTHER | ILLINOIS | MEDICARE RAILROAD |
| 4 | 200325390B | OTHER | INDIANA | IN PHYSICIANS MEDICAID |
| 5 | 833002861 | MEDICAID | ILLINOIS | |
| 6 | L77581 | OTHER | ILLINOIS | MEDICARE INDIVIDUAL PTAN |
| 7 | 205785 | OTHER | ILLINOIS | PTAN IL MEDICARE COOK COUNTY |
| 8 | P00932946 | OTHER | ILLINOIS | MEDICARE RAILROAD DUPAGE CO. INDIVIDUAL PTAN |
| 9 | 036066839 | MEDICAID | ILLINOIS | |
| 10 | 200871680B | OTHER | INDIANA | MEDICAID LOCATION CHICAGO RIDGE |
| 11 | 200871680C | OTHER | INDIANA | MEDICAID LOCATION ORLAND PARK |
| 12 | 205786 | OTHER | ILLINOIS | PTAN IL MEDICARE DUPAGE COUNTY |
| 13 | DR4230 | OTHER | ILLINOIS | MEDICARE RAILROAD GROUP PTAN DUPAGE CO. |
| 14 | 200871680D | OTHER | INDIANA | MEDICAID LOCATION HINSDALE |
| 15 | 253350 | OTHER | INDIANA | PTAN GROUP PRACTICE INDIANA MEDICARE |
