Basic Information
| Provider Information | |||||||||
| NPI: | 1336170844 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OLYMPIA FIELDS INTERNAL MEDICINE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HORIZON HEALTHCARE ASSOCIATES SC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19550 S GOVERNORS HIGHWAY | ||||||||
| Address2: | STE 2000 | ||||||||
| City: | FLOSSMOOR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604222136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089578750 | ||||||||
| FaxNumber: | 7089578602 | ||||||||
| Practice Location | |||||||||
| Address1: | 19550 S GOVERNORS HIGHWAY | ||||||||
| Address2: | STE 2000 | ||||||||
| City: | FLOSSMOOR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604222136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089578750 | ||||||||
| FaxNumber: | 7089578602 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 04/29/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GLASGOW | ||||||||
| AuthorizedOfficialFirstName: | LOIS | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | AGENT OF RECORD PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7089578750 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RN0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CA4448 | 01 | RAILROAD PALMETTO GBA | OTHER |