Provider Demographics
NPI:1598704728
Name:LEBO, NADINE KIM (MD)
Entity Type:Individual
Prefix:
First Name:NADINE
Middle Name:KIM
Last Name:LEBO
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 1:3249 SOUTH OAK PARK AVE.
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402
Mailing Address - Country:US
Mailing Address - Phone:708-783-2696
Mailing Address - Fax:708-783-3164
Practice Address - Street 1:3249 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3429
Practice Address - Country:US
Practice Address - Phone:708-783-2696
Practice Address - Fax:708-783-3164
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0979062085R0202X
IL036-979062085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036097906Medicaid
IL300113436OtherRR MEDICARE
ILL76018Medicare ID - Type Unspecified