Basic Information
Provider Information | |||||||||
NPI: | 1316163926 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ILLINOIS VALLEY EAR, NOSE & THROAT ASSOCIATES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4231 PROGRESS BLVD STE 2 | ||||||||
Address2: |   | ||||||||
City: | PERU | ||||||||
State: | IL | ||||||||
PostalCode: | 613541193 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8152240082 | ||||||||
FaxNumber: | 8152241071 | ||||||||
Practice Location | |||||||||
Address1: | 4231 PROGRESS BLVD STE 2 | ||||||||
Address2: |   | ||||||||
City: | PERU | ||||||||
State: | IL | ||||||||
PostalCode: | 613541193 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8152240082 | ||||||||
FaxNumber: | 8152241071 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/18/2007 | ||||||||
LastUpdateDate: | 01/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MAMIKOGLU | ||||||||
AuthorizedOfficialFirstName: | BULENT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
AuthorizedOfficialTelephone: | 8152240082 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: | 01/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |   | 207YX0901X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otology & Neurotology | 261QM2500X | 336-079161 | IL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
ID | Type | State | Issuer | Description | 036117864-1 | 05 | IL |   | MEDICAID |