=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912559303
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | I2 MEDICINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2019
-----------------------------------------------------
Last Update Date | 07/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 LAKE ST STE 125
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60301-6702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-490-5611
-----------------------------------------------------
Fax | 312-276-8684
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 25816
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60625-8616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-490-5611
-----------------------------------------------------
Fax | 312-276-8684
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | DOMINIC D PATAWARAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 773-490-5611
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------