Provider Demographics
NPI:1962000513
Name:MIDWEST SINUS SLEEP & ALLERGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MIDWEST SINUS SLEEP & ALLERGY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-628-0715
Mailing Address - Street 1:4224 LINCOLNSHIRE DR STE B
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2156
Mailing Address - Country:US
Mailing Address - Phone:618-816-0715
Mailing Address - Fax:888-371-4468
Practice Address - Street 1:4224 LINCOLNSHIRE DR STE B
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2156
Practice Address - Country:US
Practice Address - Phone:618-816-0715
Practice Address - Fax:888-371-4468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-15
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL137681642OtherNEW ENTITY