Basic Information
| Provider Information | |||||||||
| NPI: | 1639455173 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RUSH-COPLEY MEDICAL GROUP NFP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1256 WATERFORD DR STE 230 | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605044511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304992404 | ||||||||
| FaxNumber: | 6306925518 | ||||||||
| Practice Location | |||||||||
| Address1: | 2040 OGDEN AVE | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605047206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304992329 | ||||||||
| FaxNumber: | 6308985837 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2011 | ||||||||
| LastUpdateDate: | 02/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | BRUMMEL | ||||||||
| AuthorizedOfficialFirstName: | MARCEE | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6309784915 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0000X | 036-115418 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine | 207QA0505X | 036-115418 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207Q00000X | 036-115418 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036-115418 | 05 | IL | MEDICAID |