=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275166514
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IRA LEE WILLIAMS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2020
-----------------------------------------------------
Last Update Date | 02/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9801 S KARLOV AVE APT 203
-----------------------------------------------------
City | OAK LAWN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60453-3443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-593-5805
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9801 S KARLOV AVE APT 203
-----------------------------------------------------
City | OAK LAWN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60453-3443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-593-5805
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 347C00000X
-----------------------------------------------------
Taxonomy Name | Private Vehicle
-----------------------------------------------------
License Number | W45241279266
-----------------------------------------------------
License Number State |
-----------------------------------------------------