Basic Information
| Provider Information | |||||||||
| NPI: | 1699850610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IMLACH | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29373 NETWORK PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606731293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473905923 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4001 VOLLMER RD. | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084818883 | ||||||||
| FaxNumber: | 7084812917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 05/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036091396 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036091396 | 05 | IL | MEDICAID |