Healthcare Provider Details

I. General information

NPI: 1720448491
Provider Name (Legal Business Name): CEP AMERICA - ILLINOIS, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2016
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 ROYAL BLVD SUITE C
ELGIN IL
60123-4717
US

IV. Provider business mailing address

2100 POWELL ST STE 900
EMERYVILLE CA
94608-1844
US

V. Phone/Fax

Practice location:
  • Phone: 224-783-5611
  • Fax:
Mailing address:
  • Phone: 510-350-2644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: THEOPHILE KOURY
Title or Position: ADMINISTRATIVE VPO
Credential: MD
Phone: 510-350-2644