1396795316 NPI number — EDWARD HEALTH VENTURES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396795316 NPI number — EDWARD HEALTH VENTURES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDWARD HEALTH VENTURES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EDWARD MEDICAL GROUP
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396795316
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27555 DIEHL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARRENVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60555
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-646-3950
Provider Business Mailing Address Fax Number:
630-646-3797

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 N WEBER RD
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
BOLINGBROOK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60440-1564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-378-3400
Provider Business Practice Location Address Fax Number:
630-378-3440
Provider Enumeration Date:
05/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KOTTMAN
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
630-646-3950

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9919630 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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