Basic Information
| Provider Information | |||||||||
| NPI: | 1164689980 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUBURBAN MEDICAL CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 967 | ||||||||
| Address2: | |||||||||
| City: | TINLEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604770967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085326029 | ||||||||
| FaxNumber: | 7085326095 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 BARRINGTON RD BLDG 3 | ||||||||
| Address2: | SUITE # 2500 | ||||||||
| City: | HOFFMAN ESTATES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601691019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472268900 | ||||||||
| FaxNumber: | 2243301665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2008 | ||||||||
| LastUpdateDate: | 09/18/2009 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | RITESH | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8472268900 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 261QM2500X | 036-115260 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | 036115260 | 05 | IL | MEDICAID | 216663 | 01 | IL | MEDICARE PTAN | OTHER | 0001639510 | 01 | IL | BS PROVIDER # | OTHER |