Basic Information
| Provider Information | |||||||||
| NPI: | 1073856993 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIALYSIS OF NORTHERN ILLINOIS LLC | ||||||||
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| OtherOrganizationName: | TIMBER CREEK DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | LICENSURE AND CERTIFICATION | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153204514 | ||||||||
| FaxNumber: | 8665949961 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 S ANNIE GLIDDEN RD | ||||||||
| Address2: | |||||||||
| City: | DEKALB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601158250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157483074 | ||||||||
| FaxNumber: | 8157483148 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2013 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | WINSTEL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2537334501 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.