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General NPI Number Information
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NPI Number | 1659098101
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Entity Type | Organization
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Legal Business Name | AHS IL MEDICAL GROUP LLC
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Dates
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Enumeration Date | 10/25/2022
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Last Update Date | 10/12/2023
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Provider Practice Location Address
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Address Line | 2100 MADISON AVE
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City | GRANITE CITY
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State | IL
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Zip | 62040-4713
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Country | US
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Telephone | 818-666-0602
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Fax |
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Provider Business Mailing Address
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Address Line | 4273 S STATE ROUTE 159
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City | GLEN CARBON
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State | IL
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Zip | 62034-3224
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Country | US
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Telephone | 186-288-2297
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Fax |
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Authorized Official
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Title or Position | COMPLIANCE
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Name | JONATHAN E BURKET
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Credential |
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Telephone | 818-666-0602
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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