Healthcare Provider Details

I. General information

NPI: 1548435159
Provider Name (Legal Business Name): WILLIAMS B. EVANS MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4647 LINCOLN HWY
MATTESON IL
60443-2319
US

IV. Provider business mailing address

4647 LINCOLN HWY
MATTESON IL
60443-2319
US

V. Phone/Fax

Practice location:
  • Phone: 708-418-4200
  • Fax: 708-481-3302
Mailing address:
  • Phone: 708-418-4200
  • Fax: 708-481-3302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036062358
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier036062348
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer

VIII. Authorized Official

Name: DR. WILLIAM B EVANS
Title or Position: PRESIDENT
Credential: MD
Phone: 708-481-4200