Provider Demographics
NPI:1912292533
Name:FRESENIUS MEDICAL CARE OF ILLINOIS, LLC
Entity Type:Organization
Organization Name:FRESENIUS MEDICAL CARE OF ILLINOIS, LLC
Other - Org Name:FRESENIUS MEDICAL CARE WAUKEGAN HARBOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:110 N WEST ST
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-4330
Mailing Address - Country:US
Mailing Address - Phone:547-599-1346
Mailing Address - Fax:547-599-1351
Practice Address - Street 1:110 N WEST ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-4330
Practice Address - Country:US
Practice Address - Phone:547-599-1346
Practice Address - Fax:547-599-1351
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-10
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL142727Medicare Oscar/Certification