1962452912 NPI number — EDWARD HEALTH VENTURES

Table of content: (NPI 1962452912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962452912 NPI number — EDWARD HEALTH VENTURES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDWARD HEALTH VENTURES
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:
1962452912
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27555 DIEHL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARRENVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60555
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-646-3950
Provider Business Mailing Address Fax Number:
630-646-3797

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 N WEBER RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BOLINGBROOK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60440-1564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-646-5777
Provider Business Practice Location Address Fax Number:
630-646-5729
Provider Enumeration Date:
05/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KOTTMAN
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
630-646-3950

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9919630 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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