Provider Demographics
NPI:1447403852
Name:NEPHROLOGY ASSOCIATES OF NORTHERN ILLINOIS
Entity Type:Organization
Organization Name:NEPHROLOGY ASSOCIATES OF NORTHERN ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/COO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:O'DEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-386-1000
Mailing Address - Street 1:PO BOX 94644
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-4644
Mailing Address - Country:US
Mailing Address - Phone:630-573-5000
Mailing Address - Fax:630-368-0280
Practice Address - Street 1:650 DAKOTA ST
Practice Address - Street 2:SUITE C
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-3744
Practice Address - Country:US
Practice Address - Phone:815-301-1001
Practice Address - Fax:815-301-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-29
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110997207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1548210677OtherPROVIDER NPI NUMBER
ILI26204Medicare UPIN
IL575480005Medicare PIN