Provider Demographics
NPI:1013402825
Name:FOX RIDGE MEDICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:FOX RIDGE MEDICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:TOMLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-861-5543
Mailing Address - Street 1:3633 MUNICIPAL DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-5434
Mailing Address - Country:US
Mailing Address - Phone:779-244-3072
Mailing Address - Fax:815-331-8389
Practice Address - Street 1:3633 MUNICIPAL DR
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050
Practice Address - Country:US
Practice Address - Phone:815-861-5543
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-25
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.092485207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F100494732OtherPTAN