Provider Demographics
NPI:1134152366
Name:GREATER ELGIN EMERGENCY SPECIALISTS LTD
Entity type:Organization
Organization Name:GREATER ELGIN EMERGENCY SPECIALISTS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLIENT SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-321-8300
Mailing Address - Street 1:810 QUAIL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-6149
Mailing Address - Country:US
Mailing Address - Phone:630-321-8300
Mailing Address - Fax:630-321-8750
Practice Address - Street 1:934 CENTER ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-2125
Practice Address - Country:US
Practice Address - Phone:847-742-9800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078511207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04532206OtherBLUE CROSS & BLUE SHIELD
IL209897Medicare PIN
IL04532206OtherBLUE CROSS & BLUE SHIELD
ILDC9943Medicare PIN
IL209896Medicare PIN