Basic Information
| Provider Information | |||||||||
| NPI: | 1366727935 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVENA MERCY MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | OB LABORISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 N HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605061449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308592222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1325 N HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605061449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308592222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2011 | ||||||||
| LastUpdateDate: | 10/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | REMSEN | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6308012027 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
No ID Information.