=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841568631
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDGARDO M SARMIENTO JR. NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2011
-----------------------------------------------------
Last Update Date | 08/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 808 S WOOD 4TH FLOOR DEPT OF EMERGENCY MEDICINE UNIVERSITY OF ILLINOIS HOSPITAL
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-7300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-220-9363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 133 WILLOW BLVD
-----------------------------------------------------
City | WILLOW SPRINGS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60480-1646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-220-9363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 209009054
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------