Provider Demographics
NPI:1316103286
Name:PAULINA MED CLINIC
Entity type:Organization
Organization Name:PAULINA MED CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:RENTEA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-583-7793
Mailing Address - Street 1:3525 W PETERSON AVE
Mailing Address - Street 2:SUITE 611
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3324
Mailing Address - Country:US
Mailing Address - Phone:773-583-7793
Mailing Address - Fax:773-583-7796
Practice Address - Street 1:3525 W PETERSON AVE
Practice Address - Street 2:SUITE 611
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3324
Practice Address - Country:US
Practice Address - Phone:773-583-7793
Practice Address - Fax:773-583-7796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058737208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
714740Medicare PIN