Provider Demographics
NPI:1205845054
Name:ADI, RAFA (MD)
Entity Type:Individual
Prefix:
First Name:RAFA
Middle Name:
Last Name:ADI
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 1:1911 ROYAL BIRKDALE DR
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-4572
Mailing Address - Country:US
Mailing Address - Phone:224-628-8452
Mailing Address - Fax:
Practice Address - Street 1:6 E PHILLIP RD
Practice Address - Street 2:STE 1109
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1700
Practice Address - Country:US
Practice Address - Phone:847-362-5344
Practice Address - Fax:847-362-5332
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2019-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL55-0860163207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036087417Medicaid
IL550860163OtherTAX ID NUMBER