Provider Demographics
NPI:1679839773
Name:SOUTH BELOIT OFFICE
Entity Type:Organization
Organization Name:SOUTH BELOIT OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MR
Authorized Official - First Name:MUBEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SALEEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-616-8645
Mailing Address - Street 1:1407 PATE PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BELOIT
Mailing Address - State:IL
Mailing Address - Zip Code:61080-1431
Mailing Address - Country:US
Mailing Address - Phone:630-219-2002
Mailing Address - Fax:
Practice Address - Street 1:1407 PATE PLAZA DR
Practice Address - Street 2:
Practice Address - City:SOUTH BELOIT
Practice Address - State:IL
Practice Address - Zip Code:61080-1431
Practice Address - Country:US
Practice Address - Phone:630-219-2002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036126253208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-126253Medicaid