Healthcare Provider Details

I. General information

NPI: 1215652011
Provider Name (Legal Business Name): THE PLAINS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2022
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 E FABYAN PKWY STE 101
GENEVA IL
60134-4105
US

IV. Provider business mailing address

1541 E FABYAN PKWY
GENEVA IL
60134-4105
US

V. Phone/Fax

Practice location:
  • Phone: 630-845-9644
  • Fax: 630-845-9678
Mailing address:
  • Phone: 630-845-9644
  • Fax: 630-845-9678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGEL HEREDIA MD
Title or Position: PRESIDENT
Credential: MD
Phone: 630-845-9644