MEDICARE: DONALD R. RADEN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	036-117225	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	207844	OTHER	IL	MEDICARE GROUP NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1633897	OTHER	IL	GROUP BCBS
2	45-5547004	OTHER		GROUP TAX ID

General Provider Information

NPI Number	:	1083632384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONALD R. RADEN MD

Provider Business Mailing Address
First Line	:	200 GREEN BAY RD STE 200
Second Line	:
City	:	HIGHWOOD
State	:	IL
Zip	:	60040-1703
Country	:	US
Telephone Number	:	847-235-2139
Fax Number	:	847-615-1697

Provider Business Practice Location Address
First Line	:	200 GREEN BAY RD STE 200
Second Line	:
City	:	HIGHWOOD
State	:	IL
Zip	:	60040-1703
Country	:	US
Telephone Number	:	847-235-2139
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	03/21/2019

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