Provider Demographics
NPI:1225185135
Name:WEBSTER, RAYMOND MICHAEL (DN)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:MICHAEL
Last Name:WEBSTER
Suffix:
Gender:M
Credentials:DN
Other - Prefix:DR
Other - First Name:RAYMOND
Other - Middle Name:MICHAEL
Other - Last Name:WEBSTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DN
Mailing Address - Street 1:5510 N MENARD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-1202
Mailing Address - Country:US
Mailing Address - Phone:773-792-1288
Mailing Address - Fax:773-792-6039
Practice Address - Street 1:5510 N MENARD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-1202
Practice Address - Country:US
Practice Address - Phone:773-792-1288
Practice Address - Fax:773-792-6039
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001625441OtherBLUE CROSS BLUE SHIELD