Healthcare Provider Details

I. General information

NPI: 1669964300
Provider Name (Legal Business Name): FAVIA PRIMARY CARE, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 RYAN PARKWAY
ALGONQUIN IL
60102
US

IV. Provider business mailing address

PO BOX 336
ALGONQUIN IL
60102-0336
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-111767
License Number StateIL

VIII. Authorized Official

Name: PHILIP FAVIA
Title or Position: OWNER
Credential: MD
Phone: 815-276-0150