Healthcare Provider Details

I. General information

NPI: 1376078774
Provider Name (Legal Business Name): EDWARD HEALTH VENTURES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2017
Last Update Date: 04/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 DANADA SQ W
WHEATON IL
60189-2000
US

IV. Provider business mailing address

30 DANADA SQ W
WHEATON IL
60189-2000
US

V. Phone/Fax

Practice location:
  • Phone: 630-527-3645
  • Fax: 630-462-0305
Mailing address:
  • Phone: 630-527-3645
  • Fax: 630-462-0305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateIL

VIII. Authorized Official

Name: BILL KOTTMANN
Title or Position: PRESIDENT
Credential:
Phone: 630-646-3388