Provider Demographics
NPI:1205019270
Name:ERNESTO CABRERA MD
Entity Type:Organization
Organization Name:ERNESTO CABRERA MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:SAYSON
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MEDICAL ASSISTANT
Authorized Official - Phone:773-489-6605
Mailing Address - Street 1:1431 N WESTERN AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622
Mailing Address - Country:US
Mailing Address - Phone:773-489-6605
Mailing Address - Fax:312-633-5863
Practice Address - Street 1:1431 N WESTERN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622
Practice Address - Country:US
Practice Address - Phone:773-489-6605
Practice Address - Fax:312-633-5863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicaid
ILH49398Medicare UPIN
IL=========Medicaid