Healthcare Provider Details

I. General information

NPI: 1760587703
Provider Name (Legal Business Name): ST ANTHONY EMERGENCY SERVICES PHYSICIAN GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2875 W 19TH ST
CHICAGO IL
60623-3501
US

IV. Provider business mailing address

2001 S CALIFORNIA AVE
CHICAGO IL
60608-2486
US

V. Phone/Fax

Practice location:
  • Phone: 773-484-4783
  • Fax:
Mailing address:
  • Phone: 773-484-4783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: GUY A MEDAGLIA
Title or Position: PRESIDENT/CEO, AUTHORIZED OFFICIAL
Credential:
Phone: 773-484-1000