Provider Demographics
NPI:1568651974
Name:KISHWAUKEE INTERNIST SC
Entity Type:Organization
Organization Name:KISHWAUKEE INTERNIST SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NAUSHEEN
Authorized Official - Middle Name:ASMA
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-754-0300
Mailing Address - Street 1:2535 BETHANY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3126
Mailing Address - Country:US
Mailing Address - Phone:815-754-0300
Mailing Address - Fax:815-754-0400
Practice Address - Street 1:2535 BETHANY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3126
Practice Address - Country:US
Practice Address - Phone:815-754-0300
Practice Address - Fax:815-754-0400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH04441Medicare UPIN
IL209291Medicare PIN