Provider Demographics
NPI:1770824161
Name:BLACKBAG HOME PHYSICIAN SERVICE LLC
Entity Type:Organization
Organization Name:BLACKBAG HOME PHYSICIAN SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:NICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMPTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-399-0285
Mailing Address - Street 1:21200 S LAGRANGE RD
Mailing Address - Street 2:305
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-2003
Mailing Address - Country:US
Mailing Address - Phone:815-406-5011
Mailing Address - Fax:888-311-8610
Practice Address - Street 1:437 NAVAJO ST
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-2520
Practice Address - Country:US
Practice Address - Phone:815-406-5011
Practice Address - Fax:888-311-8610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-09
Last Update Date:2014-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service