Provider Demographics
NPI:1730211475
Name:RICARDO N. NABONG, M.D.,S.C.
Entity type:Organization
Organization Name:RICARDO N. NABONG, M.D.,S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:NABONG
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:815-344-0734
Mailing Address - Street 1:4318 W CRYSTAL LAKE RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-4210
Mailing Address - Country:US
Mailing Address - Phone:815-344-0734
Mailing Address - Fax:815-344-0485
Practice Address - Street 1:4318 W CRYSTAL LAKE RD
Practice Address - Street 2:SUITE G
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-4210
Practice Address - Country:US
Practice Address - Phone:815-344-0734
Practice Address - Fax:815-344-0485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036052875208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1578596193OtherNPI#
ILDO9728Medicare UPIN
IL208300Medicare ID - Type Unspecified