Basic Information
| Provider Information | |||||||||
| NPI: | 1487895801 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEMOREST CONSUTANTS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7255 W GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | ELMWOOD PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607072028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402790599 | ||||||||
| FaxNumber: | 4402790593 | ||||||||
| Practice Location | |||||||||
| Address1: | 7255 W GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | ELMWOOD PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607072028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402790599 | ||||||||
| FaxNumber: | 4402790593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2009 | ||||||||
| LastUpdateDate: | 03/14/2009 | ||||||||
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| AuthorizedOfficialLastName: | DEMOREST | ||||||||
| AuthorizedOfficialFirstName: | S | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4402790599 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036067738 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | IL | MEDICAID |