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Individual
NSO A NSO
Active
Individual
NSO A NSO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD MPH
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
036167294
IL
207RC0000X
Cardiovascular Disease Physician
036167294
IL
207RC0000X
Cardiovascular Disease Physician
125079225
IL
207RI0011X
Interventional Cardiology Physician
036167294
IL
208M00000X
Hospitalist Physician
Primary
036167294
IL
251E00000X
Home Health Agency
—
—
251F00000X
Home Infusion Agency
—
—
251G00000X
Community Based Hospice Care Agency
—
—
251J00000X
Nursing Care Agency
—
—
251S00000X
Community/Behavioral Health Agency
—
—
Other
Enumeration date
01/04/2018
Last updated
07/09/2026
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