Provider Demographics
NPI:1780706937
Name:NORTHERN ILLINOIS HEALTH SERVICE
Entity type:Organization
Organization Name:NORTHERN ILLINOIS HEALTH SERVICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARKE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-986-4411
Mailing Address - Street 1:1820 WINDSOR RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-4271
Mailing Address - Country:US
Mailing Address - Phone:815-986-4411
Mailing Address - Fax:815-986-4414
Practice Address - Street 1:1820 WINDSOR RD
Practice Address - Street 2:SUITE A
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-4271
Practice Address - Country:US
Practice Address - Phone:815-986-4411
Practice Address - Fax:815-986-4414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208D00000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10132041OtherBCBS
IL10132041OtherBCBS