Provider Demographics
NPI:1548441314
Name:ROGELIO LIBOON MD SC
Entity type:Organization
Organization Name:ROGELIO LIBOON MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGELIO
Authorized Official - Middle Name:N
Authorized Official - Last Name:LIBOON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-523-8014
Mailing Address - Street 1:1937 W 35TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-1206
Mailing Address - Country:US
Mailing Address - Phone:773-523-8014
Mailing Address - Fax:630-654-4362
Practice Address - Street 1:1937 W 35TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-1206
Practice Address - Country:US
Practice Address - Phone:773-523-8014
Practice Address - Fax:630-654-4362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036047971207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036047971Medicaid
ILD12578Medicare UPIN
IL036047971Medicaid