Provider Demographics
NPI:1609031079
Name:INFECTIOUS DISEASE ASSOCIATES & TRAVEL MEDICINE SC
Entity Type:Organization
Organization Name:INFECTIOUS DISEASE ASSOCIATES & TRAVEL MEDICINE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WOLLENSCHLAGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-971-9275
Mailing Address - Street 1:3825 HIGHLAND AVE
Mailing Address - Street 2:SUITE 3F TOWER I
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1552
Mailing Address - Country:US
Mailing Address - Phone:630-971-9275
Mailing Address - Fax:630-971-9293
Practice Address - Street 1:3825 HIGHLAND AVE
Practice Address - Street 2:SUITE 3F TOWER I
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1552
Practice Address - Country:US
Practice Address - Phone:630-971-9275
Practice Address - Fax:630-971-9293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4E-036065297Medicaid
IL4E-036065297Medicaid