=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689618241
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILLINOIS/INDIANA EM-I MEDICAL SERVICES, S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2006
-----------------------------------------------------
Last Update Date | 02/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7531 S STONY ISLAND AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60649-3954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-947-7500
-----------------------------------------------------
Fax | 773-947-7760
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 41494
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19101-1494
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-732-1066
-----------------------------------------------------
Fax | 630-941-4333
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. DOUGLAS P. WEBSTER
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 800-732-1066
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------