Basic Information
Provider Information | |||||||||
NPI: | 1699193003 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EDWARD HEALTH VENTURES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 27555 DIEHL RD | ||||||||
Address2: | ENTRANCE B | ||||||||
City: | WARRENVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 605553849 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6306463950 | ||||||||
FaxNumber: | 6305486832 | ||||||||
Practice Location | |||||||||
Address1: | 1828 BAY SCOTT CIR | ||||||||
Address2: | STE 112 | ||||||||
City: | NAPERVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 605401110 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6304201500 | ||||||||
FaxNumber: | 6304209895 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/02/2014 | ||||||||
LastUpdateDate: | 04/25/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KOTTMANN | ||||||||
AuthorizedOfficialFirstName: | BILL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6306463950 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.