Provider Demographics
NPI:1174590624
Name:NAB MD SC
Entity type:Organization
Organization Name:NAB MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:BLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-893-8300
Mailing Address - Street 1:400 W LAKE ST
Mailing Address - Street 2:SUITE 111A
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172
Mailing Address - Country:US
Mailing Address - Phone:630-893-8300
Mailing Address - Fax:630-893-8324
Practice Address - Street 1:400 W LAKE ST
Practice Address - Street 2:SUITE 111A
Practice Address - City:ROSELLE
Practice Address - State:IL
Practice Address - Zip Code:60172
Practice Address - Country:US
Practice Address - Phone:630-893-8300
Practice Address - Fax:630-893-8324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
210043OtherWPS GROUP #
K10906Medicare ID - Type Unspecified
E84468Medicare UPIN