Healthcare Provider Details

I. General information

NPI: 1962483123
Provider Name (Legal Business Name): ROBERT LORENZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE STE 3507
EVANSTON IL
60201-1778
US

IV. Provider business mailing address

2650 RIDGE AVE STE 3507
EVANSTON IL
60201-1778
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2868
  • Fax: 847-733-5005
Mailing address:
  • Phone: 847-570-2868
  • Fax: 847-733-5005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085001935
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: