Provider Demographics
NPI:1982004867
Name:RACETTE, PHILLIP
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:RACETTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:678 N NORTHWEST HWY
Mailing Address - Street 2:UNIT C
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-2540
Mailing Address - Country:US
Mailing Address - Phone:847-696-0040
Mailing Address - Fax:847-696-2519
Practice Address - Street 1:678 N NORTHWEST HWY
Practice Address - Street 2:UNIT C
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-2540
Practice Address - Country:US
Practice Address - Phone:847-696-0040
Practice Address - Fax:847-696-2519
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-28
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227002861171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor