Basic Information
| Provider Information | |||||||||
| NPI: | 1457395667 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MORAINE EMERGENCY PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8759 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191018759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007321066 | ||||||||
| FaxNumber: | 6309414333 | ||||||||
| Practice Location | |||||||||
| Address1: | 4102 MEDICAL CENTER DRIVE | ||||||||
| Address2: | |||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153445000 | ||||||||
| FaxNumber: | 8157594293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | WEBSTER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/GENERAL PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8007321066 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 05623906 | 01 | IL | BLUE SHIELD | OTHER |