=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447735923
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHAU MINH HA NP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2018
-----------------------------------------------------
Last Update Date | 12/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 PLEASANT AVE
-----------------------------------------------------
City | HIGHWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-432-9142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5132 N ELSTON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60630-2429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-235-6130
-----------------------------------------------------
Fax | 847-941-0577
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 209.018303
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209.018303
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------