Basic Information
| Provider Information | |||||||||
| NPI: | 1699812487 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST PHYSICIAN GROUP LTD | ||||||||
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| OtherOrganizationName: | MIDWEST PHYSICIAN CENTER OF BRIDGEPORT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20110 GOVERNORS HWY | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087477960 | ||||||||
| FaxNumber: | 7085033993 | ||||||||
| Practice Location | |||||||||
| Address1: | 3201 S WALLACE ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606163501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3123261615 | ||||||||
| FaxNumber: | 3123263910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7087477960 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0001616617 | 01 | IL | BCBS | OTHER |