Provider Demographics
NPI:1306066097
Name:SOUTH NAPERVILLE FAMILY PRACTICE, LTD.
Entity type:Organization
Organization Name:SOUTH NAPERVILLE FAMILY PRACTICE, LTD.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT/PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:STESLOW
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:630-236-4300
Mailing Address - Street 1:2020 OGDEN AVE.
Mailing Address - Street 2:SUITE 400
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-4386
Mailing Address - Country:US
Mailing Address - Phone:630-236-4300
Mailing Address - Fax:630-236-4302
Practice Address - Street 1:2020 OGDEN AVE.
Practice Address - Street 2:SUITE 400
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4386
Practice Address - Country:US
Practice Address - Phone:630-236-4300
Practice Address - Fax:630-236-4302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085042207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9915169OtherBCBS
IL9915169OtherBCBS