Basic Information
| Provider Information | |||||||||
| NPI: | 1023103769 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OAK LAWN ENDOSCOPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9921 SOUTHWEST HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084252552 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9921 SOUTHWEST HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084252552 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 10/03/2011 | ||||||||
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| AuthorizedOfficialLastName: | ARNDT | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7084259456 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 7002603 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 50226 | 01 | IL | BLUE CROSS/BLUE SHIELD | OTHER |