Provider Demographics
NPI:1699844134
Name:REGENCY MEDICAL SPA
Entity Type:Organization
Organization Name:REGENCY MEDICAL SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NADER
Authorized Official - Middle Name:
Authorized Official - Last Name:AZIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-863-8964
Mailing Address - Street 1:304 FOX GLEN CT
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-1818
Mailing Address - Country:US
Mailing Address - Phone:847-348-6425
Mailing Address - Fax:847-239-7919
Practice Address - Street 1:304 FOX GLEN CT
Practice Address - Street 2:
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-1818
Practice Address - Country:US
Practice Address - Phone:847-348-6425
Practice Address - Fax:847-239-7919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214882Medicare ID - Type UnspecifiedPROVIDER GROUP NUMBER