Provider Demographics
NPI:1144425794
Name:HENRY T PIMENTEL MDSC
Entity Type:Organization
Organization Name:HENRY T PIMENTEL MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:T
Authorized Official - Last Name:PIMENTAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-651-9200
Mailing Address - Street 1:5501 W 79TH ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BURBANK
Mailing Address - State:IL
Mailing Address - Zip Code:60459-1784
Mailing Address - Country:US
Mailing Address - Phone:773-884-4523
Mailing Address - Fax:773-884-4580
Practice Address - Street 1:326 W 64TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-3114
Practice Address - Country:US
Practice Address - Phone:773-962-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036041603208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036041603Medicaid
IL215344OtherMEDICARE PTAN
IL21623403OtherBLUE SHIELD
C41283Medicare UPIN
IL529340Medicare ID - Type Unspecified