Basic Information
| Provider Information | |||||||||
| NPI: | 1881763449 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHERN ILLINOIS EMERGENCY & OCCP MED SPEC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33786 TREASURY CTR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606943700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084607444 | ||||||||
| FaxNumber: | 7084608662 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 W NORTH AVE | ||||||||
| Address2: | |||||||||
| City: | MELROSE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601601612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086813200 | ||||||||
| FaxNumber: | 7086815228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GIACINTO | ||||||||
| AuthorizedOfficialFirstName: | HENRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7084607444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | Y | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care |
ID Information
| ID | Type | State | Issuer | Description | 01623845 | 01 | IL | BLUE CROSS & BLUE SHEILD | OTHER |