Basic Information
| Provider Information | |||||||||
| NPI: | 1043355670 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROYA FAMILY MEDICAL CENTER LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5140 | ||||||||
| Address2: | |||||||||
| City: | RIVER FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 603055140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7088650663 | ||||||||
| FaxNumber: | 7086811812 | ||||||||
| Practice Location | |||||||||
| Address1: | 714 N BROADWAY AVE. | ||||||||
| Address2: | |||||||||
| City: | MELROSE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7088650663 | ||||||||
| FaxNumber: | 7086811812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 05/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | ALEXANDRE | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7088650663 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036100953 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036100953 | 05 | IL | MEDICAID | 1626842 | 01 | IL | BCBS | OTHER |