Basic Information
| Provider Information | |||||||||
| NPI: | 1033443403 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXPERIENCE HEALTH, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3845 MCCOY DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605044429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309521412 | ||||||||
| FaxNumber: | 6309521447 | ||||||||
| Practice Location | |||||||||
| Address1: | 2850 W 95TH ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | EVERGREEN PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 608052741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309521412 | ||||||||
| FaxNumber: | 6309521447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2009 | ||||||||
| LastUpdateDate: | 10/01/2009 | ||||||||
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| AuthorizedOfficialLastName: | WEBB | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6309521412 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.