Basic Information
| Provider Information | |||||||||
| NPI: | 1083616346 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEVI | ||||||||
| FirstName: | ROBERTO | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5616 N WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606595113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738786233 | ||||||||
| FaxNumber: | 7738782688 | ||||||||
| Practice Location | |||||||||
| Address1: | 5616 N WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606595113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738786233 | ||||||||
| FaxNumber: | 7738782688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 01/23/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/20/2006 | ||||||||
| NPIReactivationDate: | 03/31/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 036050593 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036050593 | 05 | IL | MEDICAID |