MEDICARE: DR. REYNALDO ELAZEGUI NEPOMUCENO M.D.

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	207Q00000X	Family Medicine Physician	036079397	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447283692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. REYNALDO ELAZEGUI NEPOMUCENO M.D.

Provider Business Mailing Address
First Line	:	475 BROWN BLVD
Second Line	:	SUITE 106
City	:	BOURBONNAIS
State	:	IL
Zip	:	60914-2325
Country	:	US
Telephone Number	:	815-937-8786
Fax Number	:	815-937-2067

Provider Business Practice Location Address
First Line	:	475 BROWN BLVD
Second Line	:	SUITE 106
City	:	BOURBONNAIS
State	:	IL
Zip	:	60914-2325
Country	:	US
Telephone Number	:	815-937-8786
Fax Number	:	815-937-2067

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

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	03/24/2021

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