Physician Compare National (NPI:1285646588)

HEALTHCARE PROVIDER:

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1285646588
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	1951593888
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20101008001263
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	DETTORE
	Individual professional last name
Provider First Name	DIAMOND
	Individual professional first name
Provider Middle Name	D
	Individual professional middle name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	UNIVERSITY OF ILLINOIS COLLEGE OF MED (CHI/PEOR/ROCK/CHM-URB)
	Individual professional's medical school
Graduation Year	1963
	Individual professional's medical school graduation year
Primary Specialty	FAMILY MEDICINE
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Line 1 Street Address	6918 W ARCHER
	Group Practice or individual's line 1 address
Line 2 Street Address	SUITE 4
	Group Practice or individual's line 2 address
City	CHICAGO
	Group Practice or individual's city
State	IL
	Group Practice or individual's state
Zip Code	606382337
	Group Practice or individual's zip code (9 digits when available)
Phone Number	7087951520
	Phone number is listed only when there is a single phone number available for the practice location address

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	140054
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	MACNEAL HOSPITAL
	Legal business name of hospital where individual professional provides service 1
Hospital Affiliation CCN 2	140065
	Medicare CCN of hospital where individual professional provides service 2
Hospital Affiliation LBN 2	ADVENTIST LA GRANGE MEMORIAL HOSPITAL
	Legal business name of hospital where individual professional provides service 2
Hospital Affiliation CCN 3	140276
	Medicare CCN of hospital where individual professional provides service 3
Hospital Affiliation LBN 3	LOYOLA UNIVERSITY MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 3
Hospital Affiliation CCN 4	140242
	Medicare CCN of hospital where individual professional provides service 4
Hospital Affiliation LBN 4	CENTRAL DUPAGE HOSPITAL
	Legal business name of hospital where individual professional provides service 4
Professional Accepts Medicare Assignment	M