Provider Demographics
NPI:1538379516
Name:HUMBERTO VERGARA MD & ASSOCIATES SC
Entity type:Organization
Organization Name:HUMBERTO VERGARA MD & ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HUMBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:VERGARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-278-4811
Mailing Address - Street 1:1431 N WESTERN AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1797
Mailing Address - Country:US
Mailing Address - Phone:773-278-4811
Mailing Address - Fax:773-278-5920
Practice Address - Street 1:1431 N WESTERN AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1797
Practice Address - Country:US
Practice Address - Phone:773-278-4811
Practice Address - Fax:773-278-5920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-072013207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL361260Medicare PIN