Provider Demographics
NPI:1124356431
Name:FENIX FAMILY HEALTH CENTER INC.
Entity Type:Organization
Organization Name:FENIX FAMILY HEALTH CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUISE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNER-HOLMBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-909-2004
Mailing Address - Street 1:130 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60040-1122
Mailing Address - Country:US
Mailing Address - Phone:847-909-2004
Mailing Address - Fax:847-266-0961
Practice Address - Street 1:130 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:HIGHWOOD
Practice Address - State:IL
Practice Address - Zip Code:60040-1122
Practice Address - Country:US
Practice Address - Phone:847-909-2004
Practice Address - Fax:847-266-0961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-24
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
336-044483207Q00000X
IL036082171261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1679788772OtherNPI
ILE93979Medicare UPIN