Healthcare Provider Details

I. General information

NPI: 1619962859
Provider Name (Legal Business Name): NORTHERN ILLINOIS FERTILITY SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 BETHANY RD SUITE 1
DEKALB IL
60115-4908
US

IV. Provider business mailing address

625 BETHANY RD SUITE 1
DEKALB IL
60115-4908
US

V. Phone/Fax

Practice location:
  • Phone: 815-758-8621
  • Fax: 815-758-5838
Mailing address:
  • Phone: 815-758-8621
  • Fax: 815-758-5838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: JOSEPH BAUMGART
Title or Position: OWNER
Credential: MD
Phone: 815-758-8621