Provider Demographics
NPI:1760907133
Name:ILLINOIS PROFESSIONALS HEALTH PROGRAM, LLC
Entity Type:Organization
Organization Name:ILLINOIS PROFESSIONALS HEALTH PROGRAM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-892-7910
Mailing Address - Street 1:701 LEE ST STE 125
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-4539
Mailing Address - Country:US
Mailing Address - Phone:847-892-7910
Mailing Address - Fax:847-892-7911
Practice Address - Street 1:701 LEE ST STE 125
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-4539
Practice Address - Country:US
Practice Address - Phone:847-892-7910
Practice Address - Fax:847-892-7911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-07
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty