Provider Demographics
NPI:1508242629
Name:ILLIANA HOME PHYSICIAN SERVICES INC
Entity Type:Organization
Organization Name:ILLIANA HOME PHYSICIAN SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-359-4757
Mailing Address - Street 1:1609 SIBLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-2217
Mailing Address - Country:US
Mailing Address - Phone:773-359-4757
Mailing Address - Fax:
Practice Address - Street 1:1609 SIBLEY BLVD
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-2217
Practice Address - Country:US
Practice Address - Phone:773-359-4757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-31
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036087374207R00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036087374Medicaid