Healthcare Provider Details

I. General information

NPI: 1285663195
Provider Name (Legal Business Name): HENRY H. MANGURTEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 DEMPSTER ST DEPARTMENT OF PEDIATRICS-2 SOUTH BUILDING
PARK RIDGE IL
60068-1143
US

IV. Provider business mailing address

1775 DEMPSTER ST DEPARTMENT OF PEDIATRICS-2 SOUTH BUILDING
PARK RIDGE IL
60068-1143
US

V. Phone/Fax

Practice location:
  • Phone: 847-723-6973
  • Fax: 847-723-2325
Mailing address:
  • Phone: 847-723-6973
  • Fax: 847-723-2325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: