Active NPI
Edgar E Archbold, M.D
- Family Medicine Physician
- Berwyn, IL
National Provider Identifier
1801003991
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 036-069407
- Practice address
- 6917 W Cermak Rd
Berwyn, IL 60408 - Phone
- (708) 749-8190
- Fax
- (708) 749-8190
- NPI assigned
- May 17, 2007
- Last updated
- Dec 22, 2008
- 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 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 036069407 | IL | |
| Family Medicine Physician | 207Q00000X | 036-069407 | IL | Primary |
Addresses
Primary practice location
6917 W Cermak Rd
Berwyn, IL 60408
Mailing address
6917 W Cermak Rd
Berwyn, IL 60402
Phone (708) 749-8190
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 01625394 | Other | IL | BS |
| 036068407 | Medicaid | IL |
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 |
|---|---|---|---|
| 036-069407 | IL | MD | Family Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Pem Medical SC Centro Medico | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- Internal Medicine Physician
- Berwyn, IL
- NPI 1639443583
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1179360000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1229904000000",
"number": "1801003991",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "6917 W CERMAK RD",
"city": "BERWYN",
"state": "IL",
"postal_code": "60402",
"telephone_number": "708-749-8190",
"fax_number": "708-749-8190"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "6917 W CERMAK RD",
"city": "BERWYN",
"state": "IL",
"postal_code": "60408",
"telephone_number": "708-749-8190",
"fax_number": "708-749-8190"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ARCHBOLD",
"first_name": "EDGAR",
"middle_name": "E",
"credential": "M.D",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-05-17",
"last_updated": "2008-12-22",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "IL",
"license": "036069407",
"primary": false
},
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "IL",
"license": "036-069407",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BS",
"identifier": "01625394",
"state": "IL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "036068407",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Berwyn, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 22, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.