Provider Demographics
NPI:1316439722
Name:OUR MEDICAL CENTER LLC
Entity type:Organization
Organization Name:OUR MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER / PSYCH
Authorized Official - Prefix:
Authorized Official - First Name:CECILIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERUMEN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN FPA
Authorized Official - Phone:630-521-3110
Mailing Address - Street 1:451 DUNHAM RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1431
Mailing Address - Country:US
Mailing Address - Phone:630-521-3110
Mailing Address - Fax:630-296-8965
Practice Address - Street 1:451 DUNHAM RD STE 300
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1431
Practice Address - Country:US
Practice Address - Phone:630-521-3110
Practice Address - Fax:630-296-8965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013778363LP0808X, 363LP2300X, 363LP2300X
IL149017312222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1437547858OtherBLUE CROSS BLUE SHIELD