Provider Demographics
NPI:1407549421
Name:MCCOACH, RENEE A
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:A
Last Name:MCCOACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:A
Other - Last Name:PIOUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1029 E 130TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-6908
Mailing Address - Country:US
Mailing Address - Phone:773-995-6300
Mailing Address - Fax:
Practice Address - Street 1:8425 S COTTAGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-6113
Practice Address - Country:US
Practice Address - Phone:773-995-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209027293363LF0000X
IL041415206163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse