Basic Information
| Provider Information | |||||||||
| NPI: | 1649219007 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ILLINOIS MEDICAL GROUP SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4211 N CICERO AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606411651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735456900 | ||||||||
| FaxNumber: | 7736852481 | ||||||||
| Practice Location | |||||||||
| Address1: | 4211 N CICERO AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606411651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735456900 | ||||||||
| FaxNumber: | 7736852481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 06/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | ELIAS | ||||||||
| AuthorizedOfficialFirstName: | SARMED | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7735456900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | 042618822 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | DG1734 | 01 | IL | MEDICARE RAILROAD | OTHER |