Healthcare Provider Details

I. General information

NPI: 1861562175
Provider Name (Legal Business Name): GREATER VALLEY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 FOXFIELD RD SUITE 307
ST CHARLES IL
60174-5799
US

IV. Provider business mailing address

2900 FOXFIELD RD SUITE 307
ST CHARLES IL
60174-5799
US

V. Phone/Fax

Practice location:
  • Phone: 630-208-3200
  • Fax: 630-208-3203
Mailing address:
  • Phone: 630-208-3200
  • Fax: 630-208-3203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number042-007606
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number042-007606
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number042-007606
License Number StateIL

VIII. Authorized Official

Name: ROBERT E LANGMAN
Title or Position: PRESIDENT
Credential: D.O.
Phone: 630-208-3200