Provider Demographics
NPI:1861102998
Name:HIDDEN PINE FAMILY PRACTICE INC
Entity type:Organization
Organization Name:HIDDEN PINE FAMILY PRACTICE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVEROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:331-269-9896
Mailing Address - Street 1:3540 SEVEN BRIDGES DR STE 100
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-1254
Mailing Address - Country:US
Mailing Address - Phone:847-420-9664
Mailing Address - Fax:888-388-0996
Practice Address - Street 1:3540 SEVEN BRIDGES DR STE 100
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-1254
Practice Address - Country:US
Practice Address - Phone:331-269-9896
Practice Address - Fax:888-388-0996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-30
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL024794778Medicaid