1063695682 NPI number — SUBURBAN MEDICAL CENTER, S.C

Table of content: (NPI 1063695682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063695682 NPI number — SUBURBAN MEDICAL CENTER, S.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUBURBAN MEDICAL CENTER, S.C
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:
Provider Other Organization Name Type Code:
6
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:
1063695682
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 ARMY TRAIL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HANOVER PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60133-8974
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-995-9500
Provider Business Mailing Address Fax Number:
847-995-9501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
380 E NORTHWEST HWY STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DES PLAINES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60016-2274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-382-6870
Provider Business Practice Location Address Fax Number:
847-382-6083
Provider Enumeration Date:
12/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PATEL
Authorized Official First Name:
RITESH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
847-995-9500

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  036056234 , 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)

  • Identifier: 40734 . This is a "ADVOCATE PHO" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 212292 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036056234 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4900938 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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