Basic Information
| Provider Information | |||||||||
| NPI: | 1023093119 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SLADE | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1645 W JACKSON BLVD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606123276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129422200 | ||||||||
| FaxNumber: | 3129423045 | ||||||||
| Practice Location | |||||||||
| Address1: | 1645 W JACKSON BLVD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606123276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129422200 | ||||||||
| FaxNumber: | 3129423045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2005 | ||||||||
| LastUpdateDate: | 09/22/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036108763 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 036108763 | 05 | IL | MEDICAID | 01621679 | 01 | IL | BCBS OF IL | OTHER |