1114358017 NPI number — MARCON MEDICAL PARTNERS INC

Table of content: HEATHER DENISE WILLIAMS (NPI 1801082771)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114358017 NPI number — MARCON MEDICAL PARTNERS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARCON MEDICAL PARTNERS INC
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:
1114358017
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1140 N MCLEAN BLVD
Provider Second Line Business Mailing Address:
UNIT C
Provider Business Mailing Address City Name:
ELGIN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60123-1782
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
224-558-5493
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1140 N MCLEAN BLVD
Provider Second Line Business Practice Location Address:
UNIT C
Provider Business Practice Location Address City Name:
ELGIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60123-1782
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
224-558-5493
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/03/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MURTAZA
Authorized Official First Name:
SAJJAD
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
847-971-8991

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  085002516 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 036117058 , 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: 036117058 . This is a "ILLINOIS LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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