=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306090212
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEREZ HEALTH, INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2008
-----------------------------------------------------
Last Update Date | 11/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6842 W. CERMAK ROAD
-----------------------------------------------------
City | BERWYN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60402-2240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-788-0101
-----------------------------------------------------
Fax | 708-788-0109
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1451
-----------------------------------------------------
City | NORTH RIVERSIDE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60546-0851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-788-0101
-----------------------------------------------------
Fax | 708-788-0109
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. MARIA R PEREZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-788-0101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036108945
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------