Provider Demographics
NPI:1215251541
Name:JOHN V. WHITE, MD, LLC
Entity type:Organization
Organization Name:JOHN V. WHITE, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:RYJEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:847-518-1762
Mailing Address - Street 1:8816 W DEMPSTER ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-5109
Mailing Address - Country:US
Mailing Address - Phone:847-518-1762
Mailing Address - Fax:847-723-3007
Practice Address - Street 1:8816 W DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-5109
Practice Address - Country:US
Practice Address - Phone:847-518-1762
Practice Address - Fax:847-723-3007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-15
Last Update Date:2010-12-01
Deactivation Date:2010-04-05
Deactivation Code:
Reactivation Date:2010-12-01
Provider Licenses
StateLicense IDTaxonomies
IL0360672912086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067291Medicaid
IL0001632574OtherBLUECROSS/BLUESHIELD
ILC30737Medicare UPIN
IL203462Medicare PIN