Provider Demographics
NPI:1265524839
Name:HINES, RAYMOND E III (PA-C)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:E
Last Name:HINES
Suffix:III
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19110 DARVIN DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8595
Mailing Address - Country:US
Mailing Address - Phone:708-390-2290
Mailing Address - Fax:708-390-2299
Practice Address - Street 1:19110 DARVIN DR
Practice Address - Street 2:SUITE C
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8595
Practice Address - Country:US
Practice Address - Phone:708-390-2290
Practice Address - Fax:708-390-2299
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085000929363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDO9194OtherRR MEDICARE
ILDO9194OtherRR MEDICARE
ILS43291Medicare UPIN
IL201029001Medicare PIN
IN188880CMedicare PIN