Basic Information
Provider Information | |||||||||
NPI: | 1528105301 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MIDWEST PHYSICIAN GROUP LTD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MIDWEST PHYSICIAN CENTER OF ORLAND PARK | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 20110 GOVERNORS HWY | ||||||||
Address2: |   | ||||||||
City: | OLYMPIA FIELDS | ||||||||
State: | IL | ||||||||
PostalCode: | 604611030 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7087477960 | ||||||||
FaxNumber: | 7085033993 | ||||||||
Practice Location | |||||||||
Address1: | 9550 W 167TH ST | ||||||||
Address2: |   | ||||||||
City: | ORLAND PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 604675561 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7088734500 | ||||||||
FaxNumber: | 7088734505 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/31/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NELSON | ||||||||
AuthorizedOfficialFirstName: | DEBORAH | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7087477960 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology |   | 207L00000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207N00000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |   | 207RC0000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RE0101X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RG0100X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RH0003X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RN0300X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RP1001X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RR0500X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207V00000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207W00000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   | 207X00000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207Y00000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |   | 207Q00000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0001616617 | 01 | IL | BCBS | OTHER |