Basic Information
| Provider Information | |||||||||
| NPI: | 1619258118 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST FAMILY WELLNESS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 840 W IRVING PARK RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606133011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739753269 | ||||||||
| FaxNumber: | 7739753270 | ||||||||
| Practice Location | |||||||||
| Address1: | 840 W IRVING PARK RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606133011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739753269 | ||||||||
| FaxNumber: | 7739753270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2011 | ||||||||
| LastUpdateDate: | 07/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | GILLEON | ||||||||
| AuthorizedOfficialFirstName: | CHERIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7739753269 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.