1265118723 NPI number — IAS ILLINOIS PC

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 1265118723 NPI number — IAS ILLINOIS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IAS ILLINOIS PC
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:
1265118723
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7411347
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60674-3447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-987-1489
Provider Business Mailing Address Fax Number:
224-255-5813

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2525 KANEVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GENEVA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60134-2578
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-584-1400
Provider Business Practice Location Address Fax Number:
630-584-1733
Provider Enumeration Date:
06/27/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BREEDLOVE
Authorized Official First Name:
JESSE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
850-624-6138

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)