MEDICARE: DR. AMANDO A RENIVA 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	036105799	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	K01460	OTHER		MEDICARE ID #

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	1932109352	OTHER		NPI INDIVIDUAL
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932109352
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMANDO A RENIVA M.D.

Provider Business Mailing Address
First Line	:	1125 S WASHINGTON AVE
Second Line	:
City	:	PARK RIDGE
State	:	IL
Zip	:	60068-4814
Country	:	US
Telephone Number	:	847-698-0661
Fax Number	:

Provider Business Practice Location Address
First Line	:	6315 N MILWAUKEE AVE # A
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-3760
Country	:	US
Telephone Number	:	847-679-1668
Fax Number	:

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

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	06/04/2016

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