=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518359991
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RODRIGUE TINFANG MD FAMILY HEALTH LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2015
-----------------------------------------------------
Last Update Date | 09/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4909 W DIVISION ST SUITE 503
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60651-3161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-626-8833
-----------------------------------------------------
Fax | 773-626-1635
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4909 W DIVISION ST STE 503
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60651-3161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-626-8833
-----------------------------------------------------
Fax | 773-626-1635
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RODRIGUE MEYOU TINFANG
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 708-977-0196
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 036114443
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------