=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144425794
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HENRY T PIMENTEL MDSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2007
-----------------------------------------------------
Last Update Date | 12/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 326 W 64TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60621-3114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-962-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5501 W 79TH ST SUITE 400
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60459-1784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-884-4523
-----------------------------------------------------
Fax | 773-884-4580
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HENRY T PIMENTAL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 773-651-9200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 036041603
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------