Basic Information
| Provider Information | |||||||||
| NPI: | 1043237969 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONCOURSE MEDICAL ASSOCIATES, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 388320 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606388320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737674600 | ||||||||
| FaxNumber: | 7737678320 | ||||||||
| Practice Location | |||||||||
| Address1: | 5410 WARREN ST | ||||||||
| Address2: | |||||||||
| City: | MORTON GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600533639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475830939 | ||||||||
| FaxNumber: | 8475830945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 08/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | KLEMPTNER | ||||||||
| AuthorizedOfficialFirstName: | H | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8475830939 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036026661 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036026661 | 05 | IL | MEDICAID | 01607179 | 01 | IL | BLUE SHIELD | OTHER | P00134710 | 01 | RAILROAD MEDICARE | OTHER |