Provider Demographics
NPI:1962492785
Name:WILLIAM B EVANS MD SC
Entity Type:Organization
Organization Name:WILLIAM B EVANS MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-481-4200
Mailing Address - Street 1:PO BOX 429
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-0429
Mailing Address - Country:US
Mailing Address - Phone:708-747-5850
Mailing Address - Fax:708-747-9991
Practice Address - Street 1:4647 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2319
Practice Address - Country:US
Practice Address - Phone:708-481-4200
Practice Address - Fax:708-481-3302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
01622854OtherBCBSIL GROUP NUMBER
=========OtherEIN
IL201977Medicare PIN
IL146200Medicare PIN
ILD14654Medicare UPIN
=========OtherEIN
IL209094Medicare PIN