Provider Demographics
NPI:1639129554
Name:BLOCK, RENATA (PA)
Entity Type:Individual
Prefix:
First Name:RENATA
Middle Name:
Last Name:BLOCK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:150 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7553
Mailing Address - Country:US
Mailing Address - Phone:312-263-4625
Mailing Address - Fax:312-263-5029
Practice Address - Street 1:150 N MICHIGAN AVE
Practice Address - Street 2:SUITE 1200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7553
Practice Address - Country:US
Practice Address - Phone:312-263-4625
Practice Address - Fax:312-263-5029
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085-001907363A00000X
IN10004152A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085-001907Medicare ID - Type Unspecified
ILP85304Medicare UPIN