Healthcare Provider Details

I. General information

NPI: 1407996564
Provider Name (Legal Business Name): AUSENCIO NUNEZ M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 05/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1841 W ARMY TRAIL RD R
ADDISON IL
60101-1901
US

IV. Provider business mailing address

1841 W ARMY TRAIL RD R
ADDISON IL
60101-1901
US

V. Phone/Fax

Practice location:
  • Phone: 630-238-9235
  • Fax: 630-238-0426
Mailing address:
  • Phone: 630-238-9235
  • Fax: 630-238-0426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036078267
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036078267
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier036078267
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer
# 2
Identifier02205538
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBCBS PROVIDER NUMBER
# 3
Identifier363950044
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerTAXID
# 4
IdentifierCF9448
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerRAILROAD MEDICARE GROUP #

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: