Provider Demographics
NPI:1093763302
Name:IHC-SWEDISHAMERICAN EMERGENCY PHYSICIANS, LLC
Entity Type:Organization
Organization Name:IHC-SWEDISHAMERICAN EMERGENCY PHYSICIANS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KONDAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-251-1132
Mailing Address - Street 1:PO BOX 80274
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-1274
Mailing Address - Country:US
Mailing Address - Phone:414-290-6718
Mailing Address - Fax:414-290-6755
Practice Address - Street 1:1401 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2315
Practice Address - Country:US
Practice Address - Phone:414-290-6718
Practice Address - Fax:414-290-6755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL913948600Medicaid
ILDA2648OtherMEDICARE RAILROAD
IL125363600OtherOWCP
IL204472OtherFEDERAL BLACK LUNG PROGRA
WI130009490OtherWEA
WI21278000Medicaid
WI130009490OtherWEA
IL=========OtherTRICARE NORTH REGION
WI130009490OtherWEA
IL206198Medicare ID - Type Unspecified