Provider Demographics
NPI:1467696401
Name:AMG ILLINOIS LTD
Entity Type:Organization
Organization Name:AMG ILLINOIS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-647-6322
Mailing Address - Street 1:81 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:FOX LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60020-1557
Mailing Address - Country:US
Mailing Address - Phone:847-587-0115
Mailing Address - Fax:847-587-6246
Practice Address - Street 1:81 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:FOX LAKE
Practice Address - State:IL
Practice Address - Zip Code:60020-1557
Practice Address - Country:US
Practice Address - Phone:847-587-0115
Practice Address - Fax:847-587-6246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-21
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6243930001Medicare NSC