Provider Demographics
NPI:1821229006
Name:EDWARD HEALTH VENTURES
Entity Type:Organization
Organization Name:EDWARD HEALTH VENTURES
Other - Org Name:EDWARD MEDICAL GROUP - FAMILY PRACTICE CREST HILL
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-646-3950
Mailing Address - Street 1:27555 DIEHL ROAD
Mailing Address - Street 2:ENTRANCE B
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555
Mailing Address - Country:US
Mailing Address - Phone:630-646-3950
Mailing Address - Fax:630-548-6832
Practice Address - Street 1:16151 WEBER ROAD
Practice Address - Street 2:STE 201
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-0865
Practice Address - Country:US
Practice Address - Phone:815-838-2888
Practice Address - Fax:815-838-0222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-05
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9919630OtherBCBS
IL9919630OtherBCBS