Provider Demographics
NPI:1255501029
Name:EDWARD HEALTH VENTURES
Entity Type:Organization
Organization Name:EDWARD HEALTH VENTURES
Other - Org Name:EDWARD MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:KOTTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-646-3950
Mailing Address - Street 1:6701 US HIGHWAY 34
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-9129
Mailing Address - Country:US
Mailing Address - Phone:630-646-4255
Mailing Address - Fax:630-646-4256
Practice Address - Street 1:6701 US HIGHWAY 34
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-9129
Practice Address - Country:US
Practice Address - Phone:630-646-4255
Practice Address - Fax:630-646-4256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2221474OtherBCBS OF ILLINOIS
ILCC2969Medicare PIN
IL215010Medicare PIN