=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902882640
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAYMOND ROBERT OGREN A.T.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3108 S RT. 59 SUITE 136
-----------------------------------------------------
City | NAPERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-922-3844
-----------------------------------------------------
Fax | 630-922-3845
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 745 SPRINGDALE DRIVE 5
-----------------------------------------------------
City | NAPERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60540-3747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-369-1091
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------