Healthcare Provider Details

I. General information

NPI: 1316387616
Provider Name (Legal Business Name): IBSEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2013
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16003 EXECUTIVE DR
CREST HILL IL
60403-0500
US

IV. Provider business mailing address

16003 EXECUTIVE DR
CREST HILL IL
60403-0500
US

V. Phone/Fax

Practice location:
  • Phone: 815-744-2344
  • Fax:
Mailing address:
  • Phone: 815-744-2344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number036057264
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number036057264
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036057264
License Number StateIL

VIII. Authorized Official

Name: DR. RAFAEL PEREZ-GUERRA
Title or Position: PRESIDENT
Credential: MD
Phone: 815-744-2344