Healthcare Provider Details

I. General information

NPI: 1740404680
Provider Name (Legal Business Name): IMELDA A. SIA, M.D., S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 W LAKE ST
BLOOMINGDALE IL
60108-1006
US

IV. Provider business mailing address

113 W LAKE ST
BLOOMINGDALE IL
60108-1006
US

V. Phone/Fax

Practice location:
  • Phone: 630-894-8600
  • Fax: 630-894-8632
Mailing address:
  • Phone: 630-894-8600
  • Fax: 630-894-8632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. IMELDA A SIA
Title or Position: OWNER
Credential: M.D.
Phone: 630-894-8600