Provider Demographics
NPI:1316183551
Name:EDWARD HEALTH VENTURES
Entity Type:Organization
Organization Name:EDWARD HEALTH VENTURES
Other - Org Name:SANDWICH FAMILY PRACTICE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:KOTTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-646-3884
Mailing Address - Street 1:1 E COUNTYLINE RD
Mailing Address - Street 2:
Mailing Address - City:SANDWICH
Mailing Address - State:IL
Mailing Address - Zip Code:60548-2178
Mailing Address - Country:US
Mailing Address - Phone:815-786-2722
Mailing Address - Fax:815-786-6840
Practice Address - Street 1:1 E COUNTYLINE RD
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-2178
Practice Address - Country:US
Practice Address - Phone:815-786-2722
Practice Address - Fax:815-786-6840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL215010Medicare PIN