=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477798478
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHS ILLINOIS MEDICAL, S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2008
-----------------------------------------------------
Last Update Date | 02/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 OVERLOOK PT 40A-LL-WC
-----------------------------------------------------
City | LINCOLNSHIRE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60069-4302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-613-4654
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5500 MARYLAND WAY STE 400
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-4948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE V.P.
-----------------------------------------------------
Name | MR. STUART CLARK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-577-4927
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------