Organization Name: | TARGET CLINIC MEDICAL ASSOCIATES ILLINOIS LLC |
NPI Number: | 1568783140 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | KEVIN RONNEBERG (CHIEF MANAGER) |
Mailing Address: | 800 Broadview Village Sq Broadview |
State: | IL US |
Postal Code: | 601554887 |
Phone Number: | 7087315555 |
Fax Number: | |
NPI Enumeration Date: | 06/17/2010 |
NPI Last Update Date: | 11/24/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LF0000X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Family |
Taxonomy Definition: |