Provider Demographics
NPI:1013226620
Name:REGIONAL PHYSICIAN SERVICES OF ILLINOIS PC
Entity Type:Organization
Organization Name:REGIONAL PHYSICIAN SERVICES OF ILLINOIS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR, PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-862-1677
Mailing Address - Street 1:9201 E MOUNTAIN VIEW RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-5172
Mailing Address - Country:US
Mailing Address - Phone:480-862-1700
Mailing Address - Fax:480-907-1537
Practice Address - Street 1:9201 E MOUNTAIN VIEW RD
Practice Address - Street 2:SUITE 220
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258
Practice Address - Country:US
Practice Address - Phone:480-862-1700
Practice Address - Fax:480-907-1537
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY CARE HEALTH NETWORK INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-29
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty