Basic Information
| Provider Information | |||||||||
| NPI: | 1598715435 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDWARD HEALTH VENTURES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | EDWARD MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27555 DIEHL RD | ||||||||
| Address2: | |||||||||
| City: | WARRENVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306463950 | ||||||||
| FaxNumber: | 6306463797 | ||||||||
| Practice Location | |||||||||
| Address1: | 2007 95TH STREET | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305277780 | ||||||||
| FaxNumber: | 6305277777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 03/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | KOTTMAN | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6306463950 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | 2221474 | 01 | IL | BCBS | OTHER |