Basic Information
Provider Information | |||||||||
NPI: | 1508816547 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EDWARD HEALTH VENTURES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EDWARD MEDICAL GROUP | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 27555 DIEHL RD | ||||||||
Address2: |   | ||||||||
City: | WARRENVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 60555 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6306463950 | ||||||||
FaxNumber: | 6306463797 | ||||||||
Practice Location | |||||||||
Address1: | 2007 95TH ST | ||||||||
Address2: | SUITE 105 | ||||||||
City: | NAPERVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 605648459 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6306466920 | ||||||||
FaxNumber: | 6306466925 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2006 | ||||||||
LastUpdateDate: | 03/27/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KOTTMAN | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: | G. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6306463950 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
ID | Type | State | Issuer | Description | 2222385 | 01 | IL | BCBS | OTHER |