Healthcare Provider Details

I. General information

NPI: 1578658993
Provider Name (Legal Business Name): PABLO ERMELO G PEREZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 N RANDALL RD
ELGIN IL
60123-2300
US

IV. Provider business mailing address

1425 N RANDALL RD
ELGIN IL
60123-2300
US

V. Phone/Fax

Practice location:
  • Phone: 224-783-3450
  • Fax: 224-783-1124
Mailing address:
  • Phone: 224-783-3450
  • Fax: 224-783-1124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22369
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number40524
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number036-096278
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-096278
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: