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General NPI Number Information
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NPI Number | 1760495311
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Entity Type | Organization
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Legal Business Name | NEUROLOGY ASSOCIATES LTD.
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Dates
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Enumeration Date | 08/14/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 71 W 156TH ST SUITE 308
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City | HARVEY
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State | IL
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Zip | 60426-4260
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Country | US
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Telephone | 708-331-6617
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Fax | 708-331-7957
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Provider Business Mailing Address
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Address Line | 71 W 156TH ST SUITE 308
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City | HARVEY
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State | IL
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Zip | 60426-4260
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Country | US
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Telephone | 708-331-6617
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Fax | 708-331-7957
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Authorized Official
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Title or Position | PRESIDENT
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Name | KEVIN FAGAN
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Credential | MD
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Telephone | 708-331-6617
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 042-07812
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License Number State | IL
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Legacy Identifiers
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Identifier #1
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Identifier Code | 042-07812
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Identifier Type | OTHER
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Identifier State | IL
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Identifier Issuer | GROUP LICENSE NUMBER
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Identifier #2
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Identifier Code | 01617846
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Identifier Type | OTHER
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Identifier State |
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Identifier Issuer | BLUE CROSS PROVIDER NO.
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Proprietary Identifiers Ever Reported
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Identifier #1
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Identifier Code | 01617846
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Identifier Type | OTHER
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Identifier State |
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Identifier Issuer | BLUE CROSS PROVIDER NO.
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Identifier #2
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Identifier Code | 042-07812
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Identifier Type | OTHER
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Identifier State | IL
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Identifier Issuer | GROUP LICENSE NUMBER
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