Provider Demographics
NPI:1871873778
Name:AMG ILLINOIS LTD
Entity type:Organization
Organization Name:AMG ILLINOIS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BAILET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-647-3047
Mailing Address - Street 1:7505 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-1551
Mailing Address - Country:US
Mailing Address - Phone:847-746-3752
Mailing Address - Fax:
Practice Address - Street 1:7505 GRAND AVE
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-1551
Practice Address - Country:US
Practice Address - Phone:847-746-3752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-23
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6243930003Medicare NSC