Healthcare Provider Details

I. General information

NPI: 1013482470
Provider Name (Legal Business Name): EVANS O OGEBOR RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2018
Last Update Date: 10/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5159 S ASHLAND AVE
CHICAGO IL
60609-4931
US

IV. Provider business mailing address

600 W FULTON ST STE 200
CHICAGO IL
60661-1262
US

V. Phone/Fax

Practice location:
  • Phone: 773-434-9216
  • Fax: 773-434-2670
Mailing address:
  • Phone: 312-526-2411
  • Fax: 312-526-2329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number041400854
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: