Provider Demographics
NPI:1063602217
Name:SUBURBAN GYNECOLOGY, LLC
Entity type:Organization
Organization Name:SUBURBAN GYNECOLOGY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:NAHLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MERHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-685-1971
Mailing Address - Street 1:1890 SILVER CROSS BLVD
Mailing Address - Street 2:SUITE #375
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451
Mailing Address - Country:US
Mailing Address - Phone:815-717-8727
Mailing Address - Fax:815-717-8722
Practice Address - Street 1:1301 COPPERFIELD AVENUE
Practice Address - Street 2:SUITE 113
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432-2004
Practice Address - Country:US
Practice Address - Phone:815-727-7515
Practice Address - Fax:815-727-5147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107262207V00000X
IL036-107262207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14D1089841OtherCLIA
IL036107262Medicaid
ILK44404Medicare PIN
IL14D1089841OtherCLIA