Healthcare Provider Details

I. General information

NPI: 1194886754
Provider Name (Legal Business Name): COMMONWEALTH MEDICAL PHYSICIAN GROUP, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 09/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 N. SHERIDAN RD #400
CHICAGO IL
60657-6157
US

IV. Provider business mailing address

2800 N. SHERIDAN RD #400
CHICAGO IL
60657-6157
US

V. Phone/Fax

Practice location:
  • Phone: 773-472-5803
  • Fax: 773-472-7902
Mailing address:
  • Phone: 773-472-5803
  • Fax: 773-472-7902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036061003
License Number StateIL

VIII. Authorized Official

Name: MS. SHARON AFABLE
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 773-472-5803