Provider Demographics
NPI:1386644680
Name:FOX VALLEY FAMILY PHYSICIANS S.C.
Entity Type:Organization
Organization Name:FOX VALLEY FAMILY PHYSICIANS S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:D
Authorized Official - Last Name:CLADIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-232-2200
Mailing Address - Street 1:2425 FARGO BLVD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-3591
Mailing Address - Country:US
Mailing Address - Phone:630-232-2200
Mailing Address - Fax:630-232-1940
Practice Address - Street 1:2425 FARGO BLVD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-3591
Practice Address - Country:US
Practice Address - Phone:630-232-2200
Practice Address - Fax:630-232-1940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042002259207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL772060Medicare PIN