Provider Demographics
NPI:1396950739
Name:ILLINOIS INSTITUTE OF ALLERGY AND ASTHMA SC
Entity type:Organization
Organization Name:ILLINOIS INSTITUTE OF ALLERGY AND ASTHMA SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:I
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-362-0691
Mailing Address - Street 1:6 E. PHILLIP RD.
Mailing Address - Street 2:SUITE 1105
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1700
Mailing Address - Country:US
Mailing Address - Phone:847-362-0691
Mailing Address - Fax:847-362-0694
Practice Address - Street 1:6 E. PHILLIP RD.
Practice Address - Street 2:SUITE 1105
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1700
Practice Address - Country:US
Practice Address - Phone:847-362-0691
Practice Address - Fax:847-362-0694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036079245174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL023777OtherCHAMPUS
IL31603499OtherBCBS
IL927492Medicare ID - Type Unspecified
IL31603499OtherBCBS