Provider Demographics
NPI:1639323942
Name:AMANDO A RENIVA MDSC
Entity type:Organization
Organization Name:AMANDO A RENIVA MDSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDO
Authorized Official - Middle Name:A
Authorized Official - Last Name:RENIVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-698-0661
Mailing Address - Street 1:1125 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4814
Mailing Address - Country:US
Mailing Address - Phone:773-551-3570
Mailing Address - Fax:
Practice Address - Street 1:6315 N MILWAUKEE AVE # A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-3760
Practice Address - Country:US
Practice Address - Phone:847-698-0661
Practice Address - Fax:847-768-9132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-13
Last Update Date:2016-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105799207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1639323942OtherNPI GROUP
207202OtherMEDICARE PTAN
K01460OtherMEDICARE ID #
IL1932109352OtherINDIVIDUAL NPI NUMBER
207202OtherMEDICARE PTAN
IL1932109352OtherINDIVIDUAL NPI NUMBER