Basic Information
| Provider Information | |||||||||
| NPI: | 1760819650 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDWARD HEALTH VENTURES | ||||||||
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| OtherOrganizationName: | EDWARD MEDICAL GROUP WEIGHT LOSS CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 OSLER | ||||||||
| Address2: | LOWER LEVEL | ||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605407429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306463388 | ||||||||
| FaxNumber: | 6305486832 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 SPALDING DR | ||||||||
| Address2: | STE 401 | ||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605406508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305277205 | ||||||||
| FaxNumber: | 6305277139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2013 | ||||||||
| LastUpdateDate: | 12/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | KOTTMANN | ||||||||
| AuthorizedOfficialFirstName: | BILL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6306463388 | ||||||||
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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 | 207R00000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.