MEDICARE: EDWARD HEALTH VENTURES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2220936	OTHER		BCBS

General Provider Information

NPI Number	:	1205903168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDWARD HEALTH VENTURES

Provider Business Mailing Address
First Line	:	27555 DIEHL RD.
Second Line	:
City	:	WARRENVILLE
State	:	IL
Zip	:	60555
Country	:	US
Telephone Number	:	630-646-3950
Fax Number	:	630-548-6832

Provider Business Practice Location Address
First Line	:	3805 E MAIN ST
Second Line	:	STE M
City	:	ST CHARLES
State	:	IL
Zip	:	60174-2487
Country	:	US
Telephone Number	:	630-646-5200
Fax Number	:	630-646-5202

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. WILLIAM G KOTTMAN
Credential	:
Telephone Number	:	630-646-3950

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	11/10/2010

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Directions to “EDWARD HEALTH VENTURES ” Practice Location

Language	Start Address	Practice Location

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