Basic Information
| Provider Information | |||||||||
| NPI: | 1245641018 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HSHS MEDICAL GROUP INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HSHS MEDICAL GROUP FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 E ELM ST | ||||||||
| Address2: | |||||||||
| City: | STREATOR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613642223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156724587 | ||||||||
| FaxNumber: | 8156733582 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 E ELM ST | ||||||||
| Address2: | |||||||||
| City: | STREATOR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613642223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156724587 | ||||||||
| FaxNumber: | 8156733582 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2014 | ||||||||
| LastUpdateDate: | 05/27/2014 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | MELINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2174929696 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.