MEDICARE: GENERALHEALTHGROUP OF ILLINOIS

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	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1649654898	OTHER	IL	NPI

General Provider Information

NPI Number	:	1801531231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENERALHEALTHGROUP OF ILLINOIS

Provider Business Mailing Address
First Line	:	244 5TH AVE # L270
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10001-7604
Country	:	US
Telephone Number	:	917-789-5058
Fax Number	:

Provider Business Practice Location Address
First Line	:	11900 SOUTHWEST HWY STE 204
Second Line	:
City	:	PALOS PARK
State	:	IL
Zip	:	60464-1307
Country	:	US
Telephone Number	:	708-448-5800
Fax Number	:

Authorized Official
Title or Position	:	DENTAL ASSOCIATE
Name	:	CHRISTOPHER ISABELLE
Credential	:	DMD
Telephone Number	:	708-415-6507

Provider Enumeration Date	:	04/30/2022
Last Update Date	:	09/13/2023

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