1154500114 NPI number — BOLINGBROOK WOMENS CLINIC S C

Table of content: (NPI 1154500114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154500114 NPI number — BOLINGBROOK WOMENS CLINIC S C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOLINGBROOK WOMENS CLINIC 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:
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:
1154500114
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
396 REMINGTON BLVD
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-759-2966
Provider Business Mailing Address Fax Number:
630-759-6977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
396 REMINGTON BLVD
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
BOLINGBROOK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-759-2966
Provider Business Practice Location Address Fax Number:
630-759-6977
Provider Enumeration Date:
10/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KIM
Authorized Official First Name:
YONG
Authorized Official Middle Name:
J
Authorized Official Title or Position:
DR OWNER
Authorized Official Telephone Number:
630-759-2966

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , 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: 09915052 . This is a "BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 200963020A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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