Healthcare Provider Details

I. General information

NPI: 1639455173
Provider Name (Legal Business Name): RUSH-COPLEY MEDICAL GROUP NFP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2011
Last Update Date: 02/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 OGDEN AVE SUITE 303
AURORA IL
60504-7206
US

IV. Provider business mailing address

1256 WATERFORD DR STE 230
AURORA IL
60504-4511
US

V. Phone/Fax

Practice location:
  • Phone: 630-499-2329
  • Fax: 630-898-5837
Mailing address:
  • Phone: 630-499-2404
  • Fax: 630-692-5518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number036-115418
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number036-115418
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-115418
License Number StateIL

VIII. Authorized Official

Name: MARCEE A. BRUMMEL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 630-978-4915