Basic Information
| Provider Information | |||||||||
| NPI: | 1205135217 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRINCE GEORGE INTERNAL MEDICINE SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1822 SOMERSET LN | ||||||||
| Address2: | |||||||||
| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600626066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473230099 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 N RIVER RD | ||||||||
| Address2: | |||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600161209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472971800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2011 | ||||||||
| LastUpdateDate: | 05/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | AWADALLAH | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8473230099 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.