Provider Demographics
NPI:1972951192
Name:ILLINOIS HOME PROVIDERS, INC
Entity type:Organization
Organization Name:ILLINOIS HOME PROVIDERS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP-C/ PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMIREZ-TASIGCHANA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:224-505-5907
Mailing Address - Street 1:540 W FRONTAGE RD
Mailing Address - Street 2:2117
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-1250
Mailing Address - Country:US
Mailing Address - Phone:224-505-5907
Mailing Address - Fax:224-255-6057
Practice Address - Street 1:540 W FRONTAGE RD
Practice Address - Street 2:2117
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-1250
Practice Address - Country:US
Practice Address - Phone:224-505-5907
Practice Address - Fax:224-255-6057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-27
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL340766270001Medicaid
ILF400143432Medicare PIN