1407008998 NPI number — THE ILLINOIS MEDICAL ASSISTANCE TREATMENT PROGRAM LLC

Table of content: (NPI 1407008998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407008998 NPI number — THE ILLINOIS MEDICAL ASSISTANCE TREATMENT PROGRAM LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE ILLINOIS MEDICAL ASSISTANCE TREATMENT PROGRAM LLC
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:
GREEN DRAGONFLY
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:
1407008998
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1738 WASHINGTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUKEGAN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60085-5137
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-360-1019
Provider Business Mailing Address Fax Number:
847-360-6277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1738 WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUKEGAN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60085-5137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-360-1019
Provider Business Practice Location Address Fax Number:
847-360-6277
Provider Enumeration Date:
10/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KELLER
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
847-360-1019

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  A27740001A , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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