Basic Information
| Provider Information | |||||||||
| NPI: | 1902170848 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE ISLAND HBP MEDICAL GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 689022 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370689022 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 12935 GREGORY ST | ||||||||
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| City: | BLUE ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604062428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085972000 | ||||||||
| FaxNumber: | 7088244494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2012 | ||||||||
| LastUpdateDate: | 02/23/2012 | ||||||||
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| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6154657626 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VM0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 208M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.