Basic Information
| Provider Information | |||||||||
| NPI: | 1073650560 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDWEST PHYSICIAN GROUP LTD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MPC-MEDICINE & SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20110 GOVERNORS HWY | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087477960 | ||||||||
| FaxNumber: | 7085033993 | ||||||||
| Practice Location | |||||||||
| Address1: | 11250 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606434116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737797500 | ||||||||
| FaxNumber: | 7737799669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7087477960 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0001616617 | 01 | IL | BCBS | OTHER |