Provider Demographics
NPI:1770916777
Name:SYCAMORE MEDICAL ASSOCIATES LLC
Entity type:Organization
Organization Name:SYCAMORE MEDICAL ASSOCIATES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMISON
Authorized Official - Middle Name:D
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:815-748-3040
Mailing Address - Street 1:2560 HAUSER ROSS DR
Mailing Address - Street 2:SUITE 450
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3150
Mailing Address - Country:US
Mailing Address - Phone:815-748-3040
Mailing Address - Fax:815-748-3070
Practice Address - Street 1:2560 HAUSER ROSS DR
Practice Address - Street 2:SUITE 450
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3150
Practice Address - Country:US
Practice Address - Phone:815-748-3040
Practice Address - Fax:815-748-3070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-13
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103130207R00000X
IL085004109363A00000X
IL036098973207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF100098777Medicare PIN