Provider Demographics
NPI:1336170844
Name:OLYMPIA FIELDS INTERNAL MEDICINE
Entity Type:Organization
Organization Name:OLYMPIA FIELDS INTERNAL MEDICINE
Other - Org Name:HORIZON HEALTHCARE ASSOCIATES SC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AGENT OF RECORD PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:GLASGOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-957-8750
Mailing Address - Street 1:19550 S GOVERNORS HIGHWAY
Mailing Address - Street 2:STE 2000
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-2136
Mailing Address - Country:US
Mailing Address - Phone:708-957-8750
Mailing Address - Fax:708-957-8602
Practice Address - Street 1:19550 S GOVERNORS HIGHWAY
Practice Address - Street 2:STE 2000
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2136
Practice Address - Country:US
Practice Address - Phone:708-957-8750
Practice Address - Fax:708-957-8602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4448OtherRAILROAD PALMETTO GBA
IL476020Medicare ID - Type Unspecified