Basic Information
Provider Information | |||||||||
NPI: | 1780006569 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EDWARD HEALTH VENTURES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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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: | 404 W BOUGHTON RD | ||||||||
Address2: | STE A | ||||||||
City: | BOLINGBROOK | ||||||||
State: | IL | ||||||||
PostalCode: | 604401898 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6303781774 | ||||||||
FaxNumber: | 6303781789 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/13/2014 | ||||||||
LastUpdateDate: | 01/13/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KOTTMANN | ||||||||
AuthorizedOfficialFirstName: | BILL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6306463950 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: |   |
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.