Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | IL |
NPI | 1174533566 |
---|---|
Provider Name | Fares Aris |
First Address | Galesburg, IL 61401-1251 |
Second Address | Galesburg, IL 61401-1251 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C44695 | (02) | IL |
P13161 | PIN NUMBER (01) | IL |