=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023260023
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDPRO VISITING PHYSICIANS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2008
-----------------------------------------------------
Last Update Date | 10/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7518 TRIPP AVE
-----------------------------------------------------
City | SKOKIE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60076-3812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-727-2751
-----------------------------------------------------
Fax | 630-226-5390
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1571 WOODLAND LN
-----------------------------------------------------
City | BOLINGBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60490-3273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-727-2751
-----------------------------------------------------
Fax | 630-226-5390
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. ARNEL VILLAROMAN MALUNGCOT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-727-2751
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------