Provider Demographics
NPI:1578665907
Name:HOME HEALTH MEDICAL LLC
Entity Type:Organization
Organization Name:HOME HEALTH MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MANAGER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:SAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:708-422-7758
Mailing Address - Street 1:4400 W 95TH ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2654
Mailing Address - Country:US
Mailing Address - Phone:708-422-7758
Mailing Address - Fax:708-422-8154
Practice Address - Street 1:4400 W 95TH ST
Practice Address - Street 2:SUITE 106
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2654
Practice Address - Country:US
Practice Address - Phone:708-422-7758
Practice Address - Fax:708-422-8154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094623207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094623Medicaid
IL208184OtherPTAN