Healthcare Provider Details

I. General information

NPI: 1104849595
Provider Name (Legal Business Name): CARISSA BUENVENIDA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 DEMPSTER ST SUITE 555
PARK RIDGE IL
60068-1186
US

IV. Provider business mailing address

1875 DEMPSTER ST SUITE 555
PARK RIDGE IL
60068-1186
US

V. Phone/Fax

Practice location:
  • Phone: 847-698-5500
  • Fax: 847-698-0226
Mailing address:
  • Phone: 847-698-5500
  • Fax: 847-698-0226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036092596
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: