Healthcare Provider Details

I. General information

NPI: 1932221397
Provider Name (Legal Business Name): AXIS MEDICAL MANAGEMENT GOUP SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2007
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4111 W 26TH ST SUITE 110
CHICAGO IL
60623-4313
US

IV. Provider business mailing address

4111 W 26TH ST SUITE 110
CHICAGO IL
60623-4313
US

V. Phone/Fax

Practice location:
  • Phone: 773-542-1111
  • Fax: 773-542-7100
Mailing address:
  • Phone: 773-542-1111
  • Fax: 773-542-7100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number042.618397038.010225
License Number StateIL

VIII. Authorized Official

Name: JAN STRUWE
Title or Position: OFFICE MANAGER
Credential:
Phone: 773-542-1111