Provider Demographics
NPI:1194789354
Name:PRENTICE, ROBERT C (DO)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:C
Last Name:PRENTICE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:13011 S 104TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1508
Mailing Address - Country:US
Mailing Address - Phone:708-478-3600
Mailing Address - Fax:708-478-3552
Practice Address - Street 1:13011 S 104TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-1508
Practice Address - Country:US
Practice Address - Phone:708-274-3278
Practice Address - Fax:708-274-3299
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067066207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067066Medicaid
IL236551OtherMEDICARE GROUP
IL236550OtherMEDICARE GROUP
IL01621208OtherBLUE CROSS BLUE SHIELD
IL1508810086OtherGROUP NPI
IL060042297OtherRAILROAD MEDICARE COOK
IL060056572OtherRAILROAD MEDICARE WILL
ILCD8033OtherRAILROAD MEDICARE GROUP PTAN NUMBER
ILCN2703OtherRAILROAD MEDICARE GROUP PTAN NUMBER
IL060042297OtherRAILROAD MEDICARE COOK
IL01621208OtherBLUE CROSS BLUE SHIELD
IL236550OtherMEDICARE GROUP