Provider Demographics
NPI:1306039748
Name:E A DEVASSY MD AND ASSOCIATES SC
Entity Type:Organization
Organization Name:E A DEVASSY MD AND ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-588-3900
Mailing Address - Street 1:16612 W 159TH ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-8006
Mailing Address - Country:US
Mailing Address - Phone:815-588-3900
Mailing Address - Fax:815-588-1414
Practice Address - Street 1:16612 W 159TH ST
Practice Address - Street 2:SUITE 204
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-8006
Practice Address - Country:US
Practice Address - Phone:815-588-3900
Practice Address - Fax:815-588-1414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360632972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036063297Medicaid
IL208873Medicare PIN