Healthcare Provider Details

I. General information

NPI: 1447280839
Provider Name (Legal Business Name): GREATER NORTHWEST MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 BUSCH PKWY
BUFFALO GROVE IL
60089-4505
US

IV. Provider business mailing address

1300 BUSCH PKWY
BUFFALO GROVE IL
60089-4505
US

V. Phone/Fax

Practice location:
  • Phone: 847-459-7860
  • Fax: 847-541-5315
Mailing address:
  • Phone: 847-459-7860
  • Fax: 847-541-5315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. MICHAEL C HARTKE
Title or Position: ADMINISTRATOR
Credential: MBA
Phone: 847-459-7860