Healthcare Provider Details

I. General information

NPI: 1649203092
Provider Name (Legal Business Name): KORLE BU MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5517 S. ELLIS AVE
CHICAGO IL
60637
US

IV. Provider business mailing address

9033 RESERVE DR
WILLOW SPRINGS IL
60480-1655
US

V. Phone/Fax

Practice location:
  • Phone: 773-643-0400
  • Fax: 773-643-0640
Mailing address:
  • Phone: 773-643-0400
  • Fax: 773-643-0640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN ACQUAYE-AWAH
Title or Position: PRESIDENT
Credential: M.D
Phone: 773-643-0400