Basic Information
| Provider Information | |||||||||
| NPI: | 1982752911 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOULEVARD MEDICAL ASSOCIATES, SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 E 15TH ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CHICAGO HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604113459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087547777 | ||||||||
| FaxNumber: | 7087547701 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 E 15TH ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CHICAGO HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604113459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087547777 | ||||||||
| FaxNumber: | 7087547701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MANATT | ||||||||
| AuthorizedOfficialFirstName: | SAVIO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7087547777 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01623866 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |