Provider Demographics
NPI:1205054533
Name:NORTHERN ILLINOIS NEPHROLOGY
Entity type:Organization
Organization Name:NORTHERN ILLINOIS NEPHROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-398-9590
Mailing Address - Street 1:1340 CHARLES ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-2200
Mailing Address - Country:US
Mailing Address - Phone:815-398-9590
Mailing Address - Fax:815-398-9591
Practice Address - Street 1:1340 CHARLES ST
Practice Address - Street 2:SUITE 400
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2200
Practice Address - Country:US
Practice Address - Phone:815-398-9590
Practice Address - Fax:815-398-9591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty