Provider Demographics
NPI:1316387616
Name:IBSEN LLC
Entity Type:Organization
Organization Name:IBSEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ-GUERRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-744-2344
Mailing Address - Street 1:16003 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:CREST HILL
Mailing Address - State:IL
Mailing Address - Zip Code:60403-0500
Mailing Address - Country:US
Mailing Address - Phone:815-744-2344
Mailing Address - Fax:
Practice Address - Street 1:16003 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-0500
Practice Address - Country:US
Practice Address - Phone:815-744-2344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057264207QA0505X, 207QB0002X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Multi-Specialty