Provider Demographics
NPI:1376686204
Name:ANTIOCH CLINIC,LLC
Entity Type:Organization
Organization Name:ANTIOCH CLINIC,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:THAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-395-1560
Mailing Address - Street 1:707 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-1321
Mailing Address - Country:US
Mailing Address - Phone:847-395-1560
Mailing Address - Fax:847-395-4864
Practice Address - Street 1:707 MAIN ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-1321
Practice Address - Country:US
Practice Address - Phone:847-395-1560
Practice Address - Fax:847-395-4864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36070072174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC39977Medicare UPIN
IL615290Medicare ID - Type Unspecified