Provider Demographics
NPI:1417992306
Name:WESTERN SPRINGS FAMILY PRACTICE CENTER, LTD.
Entity Type:Organization
Organization Name:WESTERN SPRINGS FAMILY PRACTICE CENTER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-246-7222
Mailing Address - Street 1:5600 WOLF RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:WESTERN SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60558-2254
Mailing Address - Country:US
Mailing Address - Phone:708-246-7222
Mailing Address - Fax:
Practice Address - Street 1:5600 WOLF RD
Practice Address - Street 2:
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558-2254
Practice Address - Country:US
Practice Address - Phone:708-246-7222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL42005694207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCF5017OtherMEDICARE RAILROAD
IL1617057OtherBLUE CROSS BLUE SHIELD
IL1617057OtherBLUE CROSS BLUE SHIELD