Provider Demographics
NPI:1821296450
Name:BOLINGBROOK HEALTHCARE ASSOCIATES S.C.
Entity Type:Organization
Organization Name:BOLINGBROOK HEALTHCARE ASSOCIATES S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:MUNIRA
Authorized Official - Middle Name:MAMENDRA
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-759-9191
Mailing Address - Street 1:181 FERNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4525
Mailing Address - Country:US
Mailing Address - Phone:630-759-9191
Mailing Address - Fax:630-759-9118
Practice Address - Street 1:181 FERNWOOD DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-4525
Practice Address - Country:US
Practice Address - Phone:630-759-9191
Practice Address - Fax:630-759-9118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL201804Medicare ID - Type Unspecified