Provider Demographics
NPI:1316982846
Name:NEUROMED CLINIC LLC
Entity type:Organization
Organization Name:NEUROMED CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PATIENT SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-836-9121
Mailing Address - Street 1:3S517 WINFIELD RD
Mailing Address - Street 2:STE A
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-3159
Mailing Address - Country:US
Mailing Address - Phone:630-836-9121
Mailing Address - Fax:
Practice Address - Street 1:3S517 WINFIELD RD
Practice Address - Street 2:STE A
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-3159
Practice Address - Country:US
Practice Address - Phone:630-836-9121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207LC0200X
IL0360752022084N0400X, 2084V0102X
IL0360938212084N0400X, 2084V0102X
IL0360958422084N0400X
IL0361217312084N0600X
IL0361111362084N0600X, 2084N0400X
IL0361072342084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care MedicineGroup - Single Specialty
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular NeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111136Medicaid
IL220232500OtherDOL
IL209006135Medicaid
IL2232580OtherBCBS
IL036075202Medicaid
ILCD3784OtherGROUP RAILROAD MEDICARE
IL036107234Medicaid
IL036093821Medicaid
IL036121731Medicaid
IL1316982846Medicaid
IL1316982846Medicaid