Provider Demographics
NPI:1114178217
Name:FABIO ORTEGA MD SC
Entity Type:Organization
Organization Name:FABIO ORTEGA MD SC
Other - Org Name:FABIO ORTEGA MD SC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FABIO
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTEGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-679-3200
Mailing Address - Street 1:9933 LAWLER AVE
Mailing Address - Street 2:SUITE 409
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077
Mailing Address - Country:US
Mailing Address - Phone:847-679-3200
Mailing Address - Fax:847-679-4631
Practice Address - Street 1:9933 LAWLER AVE
Practice Address - Street 2:SUITE 409
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077
Practice Address - Country:US
Practice Address - Phone:847-679-3200
Practice Address - Fax:847-679-4631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336029781207V00000X
IL036065413207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065413Medicaid
IL31601691OtherBCBS OF ILLINOIS
IL31601691OtherBCBS OF ILLINOIS
IL211646Medicare UPIN
IL036065413Medicaid