Basic Information
| Provider Information | |||||||||
| NPI: | 1679512016 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ILLINOIS/INDIANA EM-I MEDICAL SERVICES, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 41494 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191011494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007321066 | ||||||||
| FaxNumber: | 6309414333 | ||||||||
| Practice Location | |||||||||
| Address1: | 7531 S STONY ISLAND AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606493954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739477500 | ||||||||
| FaxNumber: | 7739477792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 03/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | WEBSTER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| 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 |
No ID Information.