Basic Information
| Provider Information | |||||||||
| NPI: | 1619228723 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDWARD HEALTH VENTURES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27555 DIEHL RD | ||||||||
| Address2: | ENTRANCE B | ||||||||
| City: | WARRENVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605553849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306463950 | ||||||||
| FaxNumber: | 6305486832 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 S WEBER RD | ||||||||
| Address2: | |||||||||
| City: | ROMEOVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604464947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306463950 | ||||||||
| FaxNumber: | 6305486832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2012 | ||||||||
| LastUpdateDate: | 10/05/2012 | ||||||||
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| AuthorizedOfficialLastName: | KOTTMANN | ||||||||
| AuthorizedOfficialFirstName: | BILL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6306463950 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363A00000X | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 261Q00000X | IL | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.