Provider Demographics
NPI:1558775502
Name:MEDICAL ASSOCIATES OF ELGIN, LLC
Entity Type:Organization
Organization Name:MEDICAL ASSOCIATES OF ELGIN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:RHIT
Authorized Official - Phone:224-629-4525
Mailing Address - Street 1:1750 N RANDALL RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-7900
Mailing Address - Country:US
Mailing Address - Phone:224-629-4525
Mailing Address - Fax:847-719-0341
Practice Address - Street 1:1750 N RANDALL RD
Practice Address - Street 2:SUITE 110
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-7900
Practice Address - Country:US
Practice Address - Phone:224-629-4525
Practice Address - Fax:847-719-0341
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHAH MEDICAL ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-18
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036129040207Q00000X
IL36103130207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF100168829Medicare PIN