Provider Demographics
NPI:1881818664
Name:DOCTORS EGLY AND ASSOCIATES PC
Entity Type:Organization
Organization Name:DOCTORS EGLY AND ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:EGLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-786-6988
Mailing Address - Street 1:203 WILLOWWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-7505
Mailing Address - Country:US
Mailing Address - Phone:815-786-6988
Mailing Address - Fax:815-786-1418
Practice Address - Street 1:11 E PLEASANT AVE
Practice Address - Street 2:SUITE 129
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-1100
Practice Address - Country:US
Practice Address - Phone:815-786-6988
Practice Address - Fax:815-786-1418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060.009347 036.10105207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01932032OtherBCBS GROUP #
IL209408Medicare ID - Type UnspecifiedMEDICARE WPS GROUP #