Provider Demographics
NPI:1962452912
Name:EDWARD HEALTH VENTURES
Entity Type:Organization
Organization Name:EDWARD HEALTH VENTURES
Other - Org Name:EDWARD MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:KOTTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-646-3950
Mailing Address - Street 1:27555 DIEHL RD
Mailing Address - Street 2:
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:630-646-3797
Practice Address - Street 1:130 N WEBER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1564
Practice Address - Country:US
Practice Address - Phone:630-646-5777
Practice Address - Fax:630-646-5729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9919630OtherBCBS
IL366700Medicare PIN
ILCC2969Medicare PIN