=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659907418
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TODD RUPPAR PHD, APRN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2020
-----------------------------------------------------
Last Update Date | 03/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 S PAULINA ST STE 1080
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-3806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-942-6958
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 S PAULINA ST STE 1080
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-3806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-942-6958
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 041.458038
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 149788
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 364SG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Clinical Nurse Specialist
-----------------------------------------------------
License Number | 149788
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 364SG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Clinical Nurse Specialist
-----------------------------------------------------
License Number | 209.018331
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------