Basic Information
| Provider Information | |||||||||
| NPI: | 1851469274 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WHICHDR ENTERPRISES LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18600 GOLF LN | ||||||||
| Address2: | |||||||||
| City: | HAZEL CREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089221108 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1820 RIDGE RD STE 301 | ||||||||
| Address2: | |||||||||
| City: | HOMEWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604301759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089221108 | ||||||||
| FaxNumber: | 7089221236 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 04/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | FLAGG | ||||||||
| AuthorizedOfficialFirstName: | JEFFERY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7089221108 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS, MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | 036092720 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 21623278 | 01 | IL | BCBS | OTHER |