Healthcare Provider Details

I. General information

NPI: 1720447667
Provider Name (Legal Business Name): NEPTUNE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2016
Last Update Date: 05/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2189 N IL ROUTE 83 STE 220
ROUND LAKE BEACH IL
60073-4906
US

IV. Provider business mailing address

2189 N IL ROUTE 83 STE 220
ROUND LAKE BEACH IL
60073-4906
US

V. Phone/Fax

Practice location:
  • Phone: 312-857-5382
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number11O49IK
License Number StateZZ
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: KUMAR DINESH
Title or Position: DIRECTOR
Credential:
Phone: 312-857-5382