Provider Demographics
NPI:1669964300
Name:FAVIA PRIMARY CARE, SC
Entity type:Organization
Organization Name:FAVIA PRIMARY CARE, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:FAVIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-276-0150
Mailing Address - Street 1:PO BOX 336
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-0336
Mailing Address - Country:US
Mailing Address - Phone:815-276-0150
Mailing Address - Fax:
Practice Address - Street 1:1340 RYAN PARKWAY
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102
Practice Address - Country:US
Practice Address - Phone:815-276-0150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-30
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-111767207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty