Healthcare Provider Details

I. General information

NPI: 1740675248
Provider Name (Legal Business Name): JAMES RAGUE IV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 02/03/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

225 E CHICAGO AVE # 24
CHICAGO IL
60611-2991
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-6340
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number036.151655
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: