Healthcare Provider Details

I. General information

NPI: 1104925163
Provider Name (Legal Business Name): SOUTHWEST NEPHROLOGY ASSOCIATES, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16605 107TH ST
ORLAND PARK IL
60467-9016
US

IV. Provider business mailing address

120 W 22ND ST STE 200
OAK BROOK IL
60523-1563
US

V. Phone/Fax

Practice location:
  • Phone: 708-226-9860
  • Fax:
Mailing address:
  • Phone: 630-573-5000
  • Fax: 708-422-7816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number042618498
License Number StateIL

VIII. Authorized Official

Name: MS. NAOMI CASSIN
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 331-216-1156