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General NPI Number Information
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NPI Number | 1639323942
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Entity Type | Organization
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Legal Business Name | AMANDO A RENIVA MDSC
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Dates
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Enumeration Date | 11/13/2008
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Last Update Date | 06/04/2016
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Provider Practice Location Address
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Address Line | 6315 N MILWAUKEE AVE # A
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City | CHICAGO
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State | IL
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Zip | 60646-3760
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Country | US
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Telephone | 847-698-0661
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Fax | 847-768-9132
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Provider Business Mailing Address
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Address Line | 1125 S WASHINGTON AVE
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City | PARK RIDGE
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State | IL
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Zip | 60068-4814
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Country | US
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Telephone | 773-551-3570
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. AMANDO A RENIVA
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Credential | MD
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Telephone | 847-698-0661
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036105799
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License Number State | IL
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