Basic Information
| Provider Information | |||||||||
| NPI: | 1255660312 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALOS MEDICAL GROUP, LLC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12251 S 80TH AVE STE 1630 | ||||||||
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| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089235173 | ||||||||
| FaxNumber: | 7089235018 | ||||||||
| Practice Location | |||||||||
| Address1: | 15300 WEST AVE | ||||||||
| Address2: | |||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604624600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085905304 | ||||||||
| FaxNumber: | 7085905308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2009 | ||||||||
| LastUpdateDate: | 02/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | MOISAN | ||||||||
| AuthorizedOfficialFirstName: | TERRENCE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, CEO | ||||||||
| AuthorizedOfficialTelephone: | 7089235000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 36102101 | 05 | IL | MEDICAID |