Basic Information
| Provider Information | |||||||||
| NPI: | 1811514532 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERIDIAN PHYSICIAN GROUP PLLC | ||||||||
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| OtherOrganizationName: | MERIDIAN PHYSICIAN GROUP PLLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 N MICHIGAN AVE STE 634 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606017796 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 645 S CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606445059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736264300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2020 | ||||||||
| LastUpdateDate: | 11/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | FLORES | ||||||||
| AuthorizedOfficialFirstName: | RAMON | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRINCIPAL OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3128889153 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.