Provider Demographics
NPI:1336173509
Name:ILLINOIS UROLOGICAL INSTITUTE
Entity Type:Organization
Organization Name:ILLINOIS UROLOGICAL INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:J
Authorized Official - Last Name:TITINER
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:630-690-6400
Mailing Address - Street 1:311 SOUTH COUNTY FARM ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187
Mailing Address - Country:US
Mailing Address - Phone:630-690-6400
Mailing Address - Fax:630-690-6482
Practice Address - Street 1:311 SOUTH COUNTY FARM ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187
Practice Address - Country:US
Practice Address - Phone:630-690-6400
Practice Address - Fax:630-690-6482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2201791OtherBLUECROSS BLUESHIELD
IL360870Medicare ID - Type Unspecified