Provider Demographics
NPI:1275818098
Name:DANIEL J. PESAVENTO, M.D., P.C.
Entity Type:Organization
Organization Name:DANIEL J. PESAVENTO, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUSTINE
Authorized Official - Middle Name:R
Authorized Official - Last Name:GREENWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-382-4406
Mailing Address - Street 1:27790 W HIGHWAY 22
Mailing Address - Street 2:SUITE 37
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-2340
Mailing Address - Country:US
Mailing Address - Phone:847-382-4406
Mailing Address - Fax:847-382-7098
Practice Address - Street 1:27790 W HIGHWAY 22
Practice Address - Street 2:SUITE 37
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-2340
Practice Address - Country:US
Practice Address - Phone:847-382-4406
Practice Address - Fax:847-382-7098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-12
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091317207VG0400X
IL036065375207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG13874Medicare UPIN
ILC44337Medicare UPIN