Provider Demographics
NPI:1730203795
Name:SOUTHWEST INFECTIOUS DISEASE ASSOCIATES LTD
Entity type:Organization
Organization Name:SOUTHWEST INFECTIOUS DISEASE ASSOCIATES LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-726-1818
Mailing Address - Street 1:1051 ESSINGTON RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-2801
Mailing Address - Country:US
Mailing Address - Phone:815-726-1818
Mailing Address - Fax:815-726-0232
Practice Address - Street 1:1051 ESSINGTON RD
Practice Address - Street 2:SUITE 210
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-2801
Practice Address - Country:US
Practice Address - Phone:815-726-1818
Practice Address - Fax:815-726-0232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042006914174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210308Medicare PIN
IL5069230002Medicare NSC