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General NPI Number Information
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NPI Number | 1972307080
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Entity Type | Organization
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Legal Business Name | MEDFUSE ILLINOIS PLLC
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Dates
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Enumeration Date | 04/01/2025
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Last Update Date | 04/01/2025
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Provider Practice Location Address
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Address Line | 123 S MCKINLEY AVE
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City | RENSSELAER
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State | IN
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Zip | 47978-2949
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Country | US
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Telephone | 847-324-6800
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Fax | 224-251-7141
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Provider Business Mailing Address
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Address Line | 4711 GOLF RD STE 900
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City | SKOKIE
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State | IL
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Zip | 60076-1247
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Country | US
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Telephone | 847-234-6800
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | KENNETH GOLDMAN
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Credential |
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Telephone | 847-324-6800
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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 |
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License Number State |
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Taxonomy #2
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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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Taxonomy #3
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Taxonomy Code | 261QI0500X
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Taxonomy Name | Infusion Therapy Clinic/Center
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License Number |
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License Number State |
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