Basic Information
| Provider Information | |||||||||
| NPI: | 1134152366 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREATER ELGIN EMERGENCY SPECIALISTS LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 810 QUAIL RIDGE DR | ||||||||
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| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605596149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303218300 | ||||||||
| FaxNumber: | 6303218750 | ||||||||
| Practice Location | |||||||||
| Address1: | 934 CENTER ST | ||||||||
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| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601202125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477429800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 09/14/2009 | ||||||||
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| AuthorizedOfficialLastName: | BOSTROM | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLIENT SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 6303218300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036078511 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04532206 | 01 | IL | BLUE CROSS & BLUE SHIELD | OTHER |