1164689980 NPI number — SUBURBAN MEDICAL CENTER LLC

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 1164689980 NPI number — SUBURBAN MEDICAL CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUBURBAN MEDICAL CENTER 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:
Provider Other Organization Name Type Code:
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:
1164689980
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 967
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TINLEY PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60477-0967
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-532-6029
Provider Business Mailing Address Fax Number:
708-532-6095

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1555 BARRINGTON RD BLDG 3
Provider Second Line Business Practice Location Address:
SUITE # 2500
Provider Business Practice Location Address City Name:
HOFFMAN ESTATES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60169-1019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-226-8900
Provider Business Practice Location Address Fax Number:
224-330-1665
Provider Enumeration Date:
05/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PATEL
Authorized Official First Name:
RITESH
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
847-226-8900

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  036-115260 , 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: 036115260 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 216663 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0001639510 . This is a "BS PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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