Basic Information
| Provider Information | |||||||||
| NPI: | 1437196623 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST EMERGENCY ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 637542 | ||||||||
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| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652923000 | ||||||||
| FaxNumber: | 8654700851 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 BARRINGTON RD | ||||||||
| Address2: | ST ALEXIUS MEDICAL CENTER | ||||||||
| City: | HOFFMAN ESTATES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478432000 | ||||||||
| FaxNumber: | 6307341560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 09/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | HOLTZCLAW | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4408874718 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | CJ2285 | 01 | IL | RAILROAD | OTHER | 1437196623 | 05 | IL | MEDICAID |