Healthcare Provider Details

I. General information

NPI: 1114543055
Provider Name (Legal Business Name): MICHAEL CASTANEDA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2020
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 DEMPSTER ST STE 110
PARK RIDGE IL
60068-1125
US

IV. Provider business mailing address

8540 W ROSEVIEW DR
NILES IL
60714-1856
US

V. Phone/Fax

Practice location:
  • Phone: 847-897-9010
  • Fax:
Mailing address:
  • Phone: 847-910-6059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209021107
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: