Basic Information
| Provider Information | |||||||||
| NPI: | 1215053517 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ORTEGA | ||||||||
| FirstName: | FABIO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 RIDGE AVE ROOM 1223 | ||||||||
| Address2: | |||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600771057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475702040 | ||||||||
| FaxNumber: | 8477335315 | ||||||||
| Practice Location | |||||||||
| Address1: | 6810 N. MCCORMICK BLVD. | ||||||||
| Address2: | |||||||||
| City: | LINCOLNWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479331773 | ||||||||
| FaxNumber: | 8476791505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 09/12/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 036065413 | IL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 036065413 | 05 | IL | MEDICAID |