Healthcare Provider Details

I. General information

NPI: 1124356431
Provider Name (Legal Business Name): FENIX FAMILY HEALTH CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2009
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 WASHINGTON AVE
HIGHWOOD IL
60040-1122
US

IV. Provider business mailing address

130 WASHINGTON AVE
HIGHWOOD IL
60040-1122
US

V. Phone/Fax

Practice location:
  • Phone: 847-909-2004
  • Fax: 847-266-0961
Mailing address:
  • Phone: 847-909-2004
  • Fax: 847-266-0961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number036082171
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number336-044483
License Number State

VIII. Authorized Official

Name: DR. LOUISE BERNER-HOLMBERG
Title or Position: DIRECTOR
Credential: MD
Phone: 847-909-2004