Provider Demographics
NPI:1043410772
Name:NEUROMED CLINIC LLC
Entity Type:Organization
Organization Name:NEUROMED CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PHYSICIAN & PATIENT SVCS
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-836-9121
Mailing Address - Street 1:3S517 WINFIELD RD
Mailing Address - Street 2:STE A
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-3159
Mailing Address - Country:US
Mailing Address - Phone:630-836-9121
Mailing Address - Fax:630-836-9126
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:STE 500
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1222
Practice Address - Country:US
Practice Address - Phone:630-836-9121
Practice Address - Fax:630-836-9126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2007-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207SG0201X, 2084N0400X, 2084N0400X, 2084N0400X, 2084N0400X, 2084P0800X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty