Provider Demographics
NPI:1922214428
Name:RUBEN A INOCENCIO, MD.S.C
Entity Type:Organization
Organization Name:RUBEN A INOCENCIO, MD.S.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:INOCENCIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-406-4660
Mailing Address - Street 1:7518 TRIPP AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-3812
Mailing Address - Country:US
Mailing Address - Phone:773-447-7032
Mailing Address - Fax:847-675-8058
Practice Address - Street 1:4801 W LAKE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-2609
Practice Address - Country:US
Practice Address - Phone:773-378-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36061018207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL660620Medicare ID - Type Unspecified