=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215061239
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAZVAN G RENTEA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3525 W PETERSON AVE S.611
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60659-3324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-583-7793
-----------------------------------------------------
Fax | 773-583-7796
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6167 N CALDWELL AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60646-4838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-583-7793
-----------------------------------------------------
Fax | 773-583-7796
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------