Healthcare Provider Details

I. General information

NPI: 1295729564
Provider Name (Legal Business Name): PHILIP FAVIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 RYAN PKWY
ALGONQUIN IL
60102-4527
US

IV. Provider business mailing address

PO BOX 336
ALGONQUIN IL
60102-0336
US

V. Phone/Fax

Practice location:
  • Phone: 815-276-0150
  • Fax: 877-461-6742
Mailing address:
  • Phone: 815-276-0150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036111767
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: