Provider Demographics
NPI:1801531231
Name:GENERALHEALTHGROUP OF ILLINOIS
Entity type:Organization
Organization Name:GENERALHEALTHGROUP OF ILLINOIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTAL ASSOCIATE
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:ISABELLE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:708-415-6507
Mailing Address - Street 1:244 5TH AVE # L270
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-7604
Mailing Address - Country:US
Mailing Address - Phone:917-789-5058
Mailing Address - Fax:
Practice Address - Street 1:11900 SOUTHWEST HWY STE 204
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-1307
Practice Address - Country:US
Practice Address - Phone:708-448-5800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENERALHEALTH GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-30
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1649654898OtherNPI