Basic Information
| Provider Information | |||||||||
| NPI: | 1447403852 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEPHROLOGY ASSOCIATES OF NORTHERN ILLINOIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 94644 | ||||||||
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| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441014644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305735000 | ||||||||
| FaxNumber: | 6303680280 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 DAKOTA ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600123744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153011001 | ||||||||
| FaxNumber: | 8153011002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2008 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | O'DEA | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO/COO | ||||||||
| AuthorizedOfficialTelephone: | 7083861000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 036110997 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 1548210677 | 01 | IL | PROVIDER NPI NUMBER | OTHER |