Healthcare Provider Details

I. General information

NPI: 1699075804
Provider Name (Legal Business Name): BLUE ISLAND MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2010
Last Update Date: 10/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 W CHICAGO AVE SUITE 2
CHICAGO IL
60622
US

IV. Provider business mailing address

1802 W CHICAGO AVE SUITE 2
CHICAGO IL
60622
US

V. Phone/Fax

Practice location:
  • Phone: 773-278-2998
  • Fax:
Mailing address:
  • Phone: 773-278-2998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036090820
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036090820
License Number StateIL

VIII. Authorized Official

Name: DR. HECTOR LUIS FLORES
Title or Position: PRESIDENT
Credential: M.D.
Phone: 773-278-2998