The Illinois Medical Assistance Treatment Program LLC

Primary specialty

Clinic/CenterTaxonomy code 261Q00000X

License

A27740001A Issued in IL

Legal business name

THE ILLINOIS MEDICAL ASSISTANCE TREATMENT PROGRAM LLC

Practice address

1738 Washington St
Waukegan, IL 60085-5137

Phone

(847) 360-1019

Fax

(847) 360-6277

NPI assigned

Oct 16, 2008

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Richard L KellerNPI 1437145141

Title

Medical Director

Phone

(847) 360-1019

Specialties & licenses 1

Addresses

Other names 1

• Green Dragonfly Other name

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Richard Loran Keller, M.D.

  • Family Medicine Physician
  • Waukegan, IL
  • NPI 1437145141
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1224115200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1224115200000",
    "number": "1407008998",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1738 WASHINGTON ST",
            "city": "WAUKEGAN",
            "state": "IL",
            "postal_code": "600855137",
            "telephone_number": "847-360-1019",
            "fax_number": "847-360-6277"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1738 WASHINGTON ST",
            "city": "WAUKEGAN",
            "state": "IL",
            "postal_code": "600855137",
            "telephone_number": "847-360-1019",
            "fax_number": "847-360-6277"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE ILLINOIS MEDICAL ASSISTANCE TREATMENT PROGRAM LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-10-16",
        "last_updated": "2008-10-16",
        "status": "A",
        "authorized_official_last_name": "KELLER",
        "authorized_official_first_name": "RICHARD",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "847-360-1019",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "IL",
            "license": "A27740001A",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Green Dragonfly",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• Jascha Oscar Teibel, DPM
• Adela Tellez-Pulido
• Andres Tellez
• Vanessa Ellen Tello, RN
• Nong Thao
• The Josselyn Center NFP
• The Josselyn Center NFP
• The Terrace NH Operator LLC
• The Terrace Nursing Home,L.L.C.
• The Thresholds

• Clinic/Center in Waukegan, IL
• Providers in Waukegan, IL by specialty
• Clinic/Center in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 16, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.