Healthcare Provider Details

I. General information

NPI: 1770916777
Provider Name (Legal Business Name): SYCAMORE MEDICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2013
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2560 HAUSER ROSS DR SUITE 450
SYCAMORE IL
60178-3150
US

IV. Provider business mailing address

2560 HAUSER ROSS DR SUITE 450
SYCAMORE IL
60178-3150
US

V. Phone/Fax

Practice location:
  • Phone: 815-748-3040
  • Fax: 815-748-3070
Mailing address:
  • Phone: 815-748-3040
  • Fax: 815-748-3070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036098973
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036103130
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085004109
License Number StateIL

VIII. Authorized Official

Name: JAMISON D ALLEN
Title or Position: CO-OWNER
Credential: D.O.
Phone: 815-748-3040