Healthcare Provider Details

I. General information

NPI: 1689618241
Provider Name (Legal Business Name): ILLINOIS/INDIANA EM-I MEDICAL SERVICES, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 02/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7531 S STONY ISLAND AVE
CHICAGO IL
60649-3954
US

IV. Provider business mailing address

PO BOX 41494
PHILADELPHIA PA
19101-1494
US

V. Phone/Fax

Practice location:
  • Phone: 773-947-7500
  • Fax: 773-947-7760
Mailing address:
  • Phone: 800-732-1066
  • Fax: 630-941-4333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. DOUGLAS P. WEBSTER
Title or Position: PRESIDENT/OWNER
Credential: D.O.
Phone: 800-732-1066