Provider Demographics
NPI:1184362527
Name:PREMISE HEALTH OF ILLINOIS MEDICAL, PC
Entity type:Organization
Organization Name:PREMISE HEALTH OF ILLINOIS MEDICAL, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LEGAL COUNSEL
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-577-5893
Mailing Address - Street 1:5500 MARYLAND WAY STE 120
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4993
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6195 W. 115TH ST.
Practice Address - Street 2:
Practice Address - City:ALSIP
Practice Address - State:IL
Practice Address - Zip Code:60803
Practice Address - Country:US
Practice Address - Phone:312-262-7002
Practice Address - Fax:312-262-7005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-25
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty