Basic Information
| Provider Information | |||||||||
| NPI: | 1942489075 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEERPATH PHYSICIANS GROUP LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 731 S. ILLINOIS ROUTE 21 | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600313813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475663337 | ||||||||
| FaxNumber: | 8478163166 | ||||||||
| Practice Location | |||||||||
| Address1: | 731 S ILLINOIS ROUTE 21 | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600313813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475663337 | ||||||||
| FaxNumber: | 8478163166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2007 | ||||||||
| LastUpdateDate: | 08/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | SAVIN | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8475663337 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04930281 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |