Provider Demographics
NPI:1427148329
Name:SUBURBAN EAR,NOSE & THROAT ASSOC., LTD.
Entity type:Organization
Organization Name:SUBURBAN EAR,NOSE & THROAT ASSOC., LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LON
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETCHENIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-259-2530
Mailing Address - Street 1:5999 NEW WILKE RD BLDG 1
Mailing Address - Street 2:
Mailing Address - City:ROLLING MEADOWS
Mailing Address - State:IL
Mailing Address - Zip Code:60008-4506
Mailing Address - Country:US
Mailing Address - Phone:847-259-2530
Mailing Address - Fax:847-259-4930
Practice Address - Street 1:5999 NEW WILKE RD BLDG 1
Practice Address - Street 2:
Practice Address - City:ROLLING MEADOWS
Practice Address - State:IL
Practice Address - Zip Code:60008-4506
Practice Address - Country:US
Practice Address - Phone:847-259-2530
Practice Address - Fax:847-259-4930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01616074OtherBLUE CROSS
ILCF1147OtherRAILROAD MEDICARE
IL01616074OtherBLUE CROSS