MEDICARE: CARY GROVE MEDICAL ASSOCIATES, S.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305R00000X	Preferred Provider Organization		IL

General Provider Information

NPI Number	:	1780715292
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARY GROVE MEDICAL ASSOCIATES, S.C.

Provider Business Mailing Address
First Line	:	7105 N. VIRGINIA ROAD
Second Line	:	UNIT 7
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-7986
Country	:	US
Telephone Number	:	815-444-1913
Fax Number	:	815-444-1951

Provider Business Practice Location Address
First Line	:	7105 VIRGINIA RD STE 7
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-7986
Country	:	US
Telephone Number	:	815-444-1913
Fax Number	:	815-444-1951

Authorized Official
Title or Position	:	MEDICAL DOCTOR
Name	:	DR. SOL BICOMONG DAYA
Credential	:	M.D.
Telephone Number	:	815-444-1913

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	08/22/2020

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