Active NPI
Reynaldo Elazegui Nepomuceno, M.D.
- Family Medicine Physician
- Bourbonnais, IL
National Provider Identifier
1447283692
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 036079397
- Practice address
- 475 Brown Blvd
Suite 106
Bourbonnais, IL 60914-2325 - Phone
- (815) 937-8786
- Fax
- (815) 937-2067
- NPI assigned
- Jul 9, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 036079397 | IL | Primary |
Addresses
Primary practice location
475 Brown Blvd
Suite 106
Bourbonnais, IL 60914-2325
Mailing address
475 Brown Blvd
Suite 106
Bourbonnais, IL 60914-2325
Phone (815) 937-8786
Other practice location 1
656 N Convent St Ste B
Bourbonnais, IL 60914-1393
Phone (815) 936-5186
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 036079397 | Medicaid | IL |
Electronic endpoints 1
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| Direct Messaging Address | rnepomuceno48240@ce-direct.presencehealth.org |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 036079397 | IL | MD | Family Medicine Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1152403200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1616544000000",
"number": "1447283692",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "475 BROWN BLVD",
"address_2": "SUITE 106",
"city": "BOURBONNAIS",
"state": "IL",
"postal_code": "609142325",
"telephone_number": "815-937-8786",
"fax_number": "815-937-2067"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "475 BROWN BLVD",
"address_2": "SUITE 106",
"city": "BOURBONNAIS",
"state": "IL",
"postal_code": "609142325",
"telephone_number": "815-937-8786",
"fax_number": "815-937-2067"
}
],
"practiceLocations": [
{
"address_1": "656 N Convent St Ste B",
"address_purpose": "LOCATION",
"city": "Bourbonnais",
"state": "IL",
"postal_code": "609141393",
"country_code": "US",
"telephone_number": "815-936-5186",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "NEPOMUCENO",
"first_name": "REYNALDO",
"middle_name": "ELAZEGUI",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-07-09",
"last_updated": "2021-03-24",
"certification_date": "2021-03-24",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "IL",
"license": "036079397",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "036079397",
"state": "IL"
}
],
"endpoints": [
{
"endpointType": "DIRECT",
"endpointTypeDescription": "Direct Messaging Address",
"endpoint": "rnepomuceno48240@ce-direct.presencehealth.org",
"affiliation": "N",
"address_1": "656 N Convent St Ste B",
"city": "Bourbonnais",
"state": "IL",
"country_code": "US",
"postal_code": "609141393",
"country_name": "United States",
"address_type": "DOM"
}
],
"other_names": []
}Other providers in Bourbonnais, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 24, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.