Provider Demographics
NPI:1164603056
Name:OTTO R GARCIA MONTENEGRO MD INC
Entity Type:Organization
Organization Name:OTTO R GARCIA MONTENEGRO MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OTTO
Authorized Official - Middle Name:R
Authorized Official - Last Name:GARCIA MONTENEGRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-345-4554
Mailing Address - Street 1:1119 N 25TH AVE STE D
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-3068
Mailing Address - Country:US
Mailing Address - Phone:708-345-4554
Mailing Address - Fax:708-345-5253
Practice Address - Street 1:1119 N 25TH AVE STE D
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-3068
Practice Address - Country:US
Practice Address - Phone:708-345-4554
Practice Address - Fax:708-345-5253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209661Medicare PIN
ILG97829Medicare UPIN