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 | 363L00000X | Nurse Practitioner | | 42007401 | ILLINOIS | No |
| 2 | 207RC0001X | Internal Medicine | Clinical Cardiac Electrophysiology | 42007401 | ILLINOIS | No |
| 3 | 207RC0000X | Internal Medicine | Cardiovascular Disease | 42007401 | 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 | 0503174 | OTHER | ILLINOIS | CIGNA |
| 2 | 343940 | OTHER | ILLINOIS | LOCALITY 16 |
| 3 | 1146003 | OTHER | ILLINOIS | UNITED HEALTHCARE |
| 4 | CM9413 | MEDICARE ID-TYPE UNSPECIFIED | ILLINOIS | RAILROAD LOCALITY 16 |
| 5 | 209912 | MEDICARE PIN | ILLINOIS | |
| 6 | 4478598 | OTHER | ILLINOIS | AETNA |
| 7 | 200751 | MEDICARE ID-TYPE UNSPECIFIED | ILLINOIS | LOCALITY 099 |
| 8 | 519500 | MEDICARE ID-TYPE UNSPECIFIED | ILLINOIS | LOCALITY 15 |
| 9 | CI2541 | MEDICARE ID-TYPE UNSPECIFIED | ILLINOIS | RAILROAD LOCALITY 15 |
| 10 | 209909 | MEDICARE PIN | ILLINOIS | |
| 11 | 1619483 | OTHER | ILLINOIS | BCBS |
