1235184276 NPI number — ELK GROVE INTERNAL MEDICINE ASSOCIATES, S.C.

Table of content: (NPI 1235184276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235184276 NPI number — ELK GROVE INTERNAL MEDICINE ASSOCIATES, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELK GROVE INTERNAL MEDICINE ASSOCIATES, 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:
1235184276
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 BIESTERFIELD RD
Provider Second Line Business Mailing Address:
SUITE 505
Provider Business Mailing Address City Name:
ELK GROVE VILLAGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60007-3311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-437-5843
Provider Business Mailing Address Fax Number:
847-437-5859

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 BIESTERFIELD RD
Provider Second Line Business Practice Location Address:
SUITE 505
Provider Business Practice Location Address City Name:
ELK GROVE VILLAGE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60007-3311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-437-5843
Provider Business Practice Location Address Fax Number:
847-437-5859
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOODMAN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
847-437-5843

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  042-001731 , 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: 603670 . This is a "MEDICARE LEGACY" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: C12505 . This is a "RAILROAD RR MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1615451 . This is a "BLUE CROSS BLUE SHIELD ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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