Provider Demographics
NPI:1699062141
Name:AMG ILLINOIS LTD
Entity type:Organization
Organization Name:AMG ILLINOIS LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BAILET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-647-6322
Mailing Address - Street 1:3115 LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:ZION
Mailing Address - State:IL
Mailing Address - Zip Code:60099-3096
Mailing Address - Country:US
Mailing Address - Phone:847-746-3752
Mailing Address - Fax:
Practice Address - Street 1:3115 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099-3096
Practice Address - Country:US
Practice Address - Phone:847-746-3752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-06
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6243930004Medicare NSC