Provider Demographics
NPI:1659601862
Name:DENENBERG MEDICAL SC
Entity Type:Organization
Organization Name:DENENBERG MEDICAL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:DENENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-679-6707
Mailing Address - Street 1:4905 OLD ORCHARD CTR
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1458
Mailing Address - Country:US
Mailing Address - Phone:847-679-6707
Mailing Address - Fax:847-679-6721
Practice Address - Street 1:4905 OLD ORCHARD CTR
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1458
Practice Address - Country:US
Practice Address - Phone:847-679-6707
Practice Address - Fax:847-679-6721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-11
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098295207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01637204OtherBLUE CROSS BLUE SHIELD
IL01637204OtherBLUE CROSS BLUE SHIELD