Basic Information
| Provider Information | |||||||||
| NPI: | 1679745293 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RUSH-COPLEY MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1256 WATERFORD DR STE 230 | ||||||||
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| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605044511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304992404 | ||||||||
| FaxNumber: | 6306925518 | ||||||||
| Practice Location | |||||||||
| Address1: | 2040 OGDEN AVE | ||||||||
| Address2: | STE 30 | ||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605047222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309786770 | ||||||||
| FaxNumber: | 6309786773 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2008 | ||||||||
| LastUpdateDate: | 02/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | BRUMMEL | ||||||||
| AuthorizedOfficialFirstName: | MARCEE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6309784915 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RUSH-COPLEY MEDICAL GROUP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 036-110500 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 208039 | 01 | IL | MEDICARE GROUP | OTHER |