Basic Information
| Provider Information | |||||||||
| NPI: | 1194981019 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLOMGREN | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 WESTBROOK CORPORATE CTR | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | WESTCHESTER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601545701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082362673 | ||||||||
| FaxNumber: | 7084925673 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 N WINFIELD ROAD | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601901295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306825653 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2008 | ||||||||
| LastUpdateDate: | 09/18/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 036-122632 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | 036-122632 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1633878 | 01 | IL | BCBS | OTHER | 9084591 | 01 | IL | AETNA | OTHER | P01010062 | 01 | IL | RR MEDICARE | OTHER | 036122632 1 | 05 | IL | MEDICAID |