Provider Demographics
NPI:1962497735
Name:NORTHERN ILLINOIS HOME MEDICAL SUPPLY
Entity Type:Organization
Organization Name:NORTHERN ILLINOIS HOME MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LESAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-284-8200
Mailing Address - Street 1:1309 N GALENA AVE
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-1060
Mailing Address - Country:US
Mailing Address - Phone:815-285-5857
Mailing Address - Fax:815-285-5858
Practice Address - Street 1:1309 N GALENA AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-1060
Practice Address - Country:US
Practice Address - Phone:815-285-5857
Practice Address - Fax:815-285-5858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
072724OtherHEALTH ALLIANCE MED PLANS
IL09832001OtherBLUE CROSS BLUE SHIELD
IL=========002Medicaid
4361270002Medicare ID - Type Unspecified