Provider Demographics
NPI:1821105560
Name:FOX VALLEY UROLOGY S.C.
Entity Type:Organization
Organization Name:FOX VALLEY UROLOGY S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AZEEM
Authorized Official - Middle Name:S
Authorized Official - Last Name:HALEEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-786-9988
Mailing Address - Street 1:1310 N MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SANDWICH
Mailing Address - State:IL
Mailing Address - Zip Code:60548-1394
Mailing Address - Country:US
Mailing Address - Phone:815-786-9988
Mailing Address - Fax:815-786-9986
Practice Address - Street 1:1310 N MAIN
Practice Address - Street 2:SUITE 200
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-1394
Practice Address - Country:US
Practice Address - Phone:815-786-9988
Practice Address - Fax:815-786-9986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084000208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036084000Medicaid
ILF25637Medicare UPIN