Healthcare Provider Details

I. General information

NPI: 1811514532
Provider Name (Legal Business Name): MERIDIAN PHYSICIAN GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2020
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 S CENTRAL AVE
CHICAGO IL
60644-5059
US

IV. Provider business mailing address

155 N MICHIGAN AVE STE 634
CHICAGO IL
60601-7796
US

V. Phone/Fax

Practice location:
  • Phone: 773-626-4300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: RAMON FLORES
Title or Position: PRINCIPAL OWNER
Credential: MD
Phone: 312-888-9153