Provider Demographics
NPI: | 1154302685 |
---|---|
Name: | NEPOMUCENO, ARSENIA M (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | ARSENIA |
Middle Name: | M |
Last Name: | NEPOMUCENO |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 35318 EAGLE WAY |
Mailing Address - Street 2: | |
Mailing Address - City: | CHICAGO |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60678-1353 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 317-528-4800 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 3700 W 203RD ST STE 301 |
Practice Address - Street 2: | |
Practice Address - City: | OLYMPIA FIELDS |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60461-1182 |
Practice Address - Country: | US |
Practice Address - Phone: | 708-679-2850 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-11-10 |
Last Update Date: | 2022-12-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 036069960 | 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 1124322680 | Other | GROUP NPI |
IL | 364317999 | Other | TAX ID |
IL | 036069960 | Medicaid | |
IL | IL5686007 | Other | MEDICARE PTAN |
IL | 806290 | Other | MEDICARE GROUP PTAN |
IL | 364317999 | Other | TAX ID |
IL | C48377 | Medicare UPIN |