Provider Demographics
NPI:1437184363
Name:PREMIER WOMENS HEALTH ASSOCIATES SC
Entity Type:Organization
Organization Name:PREMIER WOMENS HEALTH ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:COPLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-289-8262
Mailing Address - Street 1:1710 N RANDALL RD
Mailing Address - Street 2:SUITE 360
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-9400
Mailing Address - Country:US
Mailing Address - Phone:847-289-8262
Mailing Address - Fax:847-214-5745
Practice Address - Street 1:1710 N RANDALL RD
Practice Address - Street 2:SUITE 360
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-9400
Practice Address - Country:US
Practice Address - Phone:847-289-8262
Practice Address - Fax:847-214-5745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084462207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05632088OtherBLUE CROSS/BLUE SHIELD
IL208603Medicare PIN
IL05632088OtherBLUE CROSS/BLUE SHIELD
ILDG3689Medicare PIN