Basic Information
| Provider Information | |||||||||
| NPI: | 1386171163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBINSON | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 MCCLINTOCK DR | ||||||||
| Address2: | STE 202 | ||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605270871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882206432 | ||||||||
| FaxNumber: | 6306544253 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 MCCLINTOCK DR | ||||||||
| Address2: | STE 202 | ||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605270871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882206432 | ||||||||
| FaxNumber: | 6306544253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2017 | ||||||||
| LastUpdateDate: | 09/11/2017 | ||||||||
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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 | 363AM0700X | 085006280 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 085006280 | 05 | IL | MEDICAID |