Provider Demographics
NPI:1679605737
Name:PSYCHIATRIC CLINICS OF NORTHERN ILLINOIS PC
Entity type:Organization
Organization Name:PSYCHIATRIC CLINICS OF NORTHERN ILLINOIS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:AZAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-229-7227
Mailing Address - Street 1:1639 N ALPINE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1449
Mailing Address - Country:US
Mailing Address - Phone:815-229-7227
Mailing Address - Fax:815-229-7288
Practice Address - Street 1:1639 N ALPINE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1449
Practice Address - Country:US
Practice Address - Phone:815-229-7227
Practice Address - Fax:815-229-7288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360793352084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0010100667OtherBCBS OF ILLINOIS
IL912800Medicare ID - Type Unspecified