Provider Demographics
NPI:1124262944
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:
Authorized Official - Last Name:BAILET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-647-6322
Mailing Address - Street 1:45 TOWER CT
Mailing Address - Street 2:SUITE C
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3376
Mailing Address - Country:US
Mailing Address - Phone:847-623-3200
Mailing Address - Fax:847-623-9168
Practice Address - Street 1:45 TOWER CT
Practice Address - Street 2:SUITE C
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3376
Practice Address - Country:US
Practice Address - Phone:847-623-3200
Practice Address - Fax:847-623-9168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-23
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6243930002Medicare NSC