Provider Demographics
NPI:1619603065
Name:DAVENPORT MEDICAL INC
Entity Type:Organization
Organization Name:DAVENPORT MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-543-8964
Mailing Address - Street 1:1023 MAPLETON AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1405
Mailing Address - Country:US
Mailing Address - Phone:773-543-8964
Mailing Address - Fax:
Practice Address - Street 1:1023 MAPLETON AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1405
Practice Address - Country:US
Practice Address - Phone:773-543-8964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036114303Medicaid