Basic Information
| Provider Information | |||||||||
| NPI: | 1467405985 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST PHYSICIAN GROUP LTD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20110 GOVERNORS HWY | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087477960 | ||||||||
| FaxNumber: | 7085033993 | ||||||||
| Practice Location | |||||||||
| Address1: | 20110 GOVERNORS HWY | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087477960 | ||||||||
| FaxNumber: | 7085033993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 12/10/2007 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7087477960 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 42005377 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CA1946 | 01 | IL | RAILROAD MEDICARE GROUP | OTHER | CA7850 | 01 | IL | RAILROAD MEDICARE GROUP | OTHER | CD4066 | 01 | IL | RAILROAD MEDICARE GROUP | OTHER | C10237 | 01 | IL | RAILROAD MEDICARE GROUP | OTHER | 0001616617 | 01 | IL | BLUE SHIELD ID | OTHER | CC6202 | 01 | IL | RAILROAD MEDICARE GROUP | OTHER |