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	261QM1300X	Multi-Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2222385	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1508816547
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	:	630-646-3797

Provider Business Practice Location Address
First Line	:	2007 95TH ST
Second Line	:	SUITE 105
City	:	NAPERVILLE
State	:	IL
Zip	:	60564-8459
Country	:	US
Telephone Number	:	630-646-6920
Fax Number	:	630-646-6925

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

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	03/27/2009

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Directions to “EDWARD HEALTH VENTURES ” Practice Location

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