Basic Information
| Provider Information | |||||||||
| NPI: | 1265655534 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DREYER MEDICAL GROUP LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2357 SEQUOIA DR | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605066222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308596800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 80 TEMPLETON DR | ||||||||
| Address2: | |||||||||
| City: | OSWEGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605437000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305543456 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 12/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | ROSALES | ||||||||
| AuthorizedOfficialFirstName: | SUZANNE | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6309073944 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DREYER CLINIC, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 04515143 | 01 | IL | BLUE SHIELD PROVIDER # | OTHER |