Healthcare Provider Details

I. General information

NPI: 1548532351
Provider Name (Legal Business Name): INDEPENDENT PHYSICIAN GROUP OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E WACKER DR SUITE 107
CHICAGO IL
60601-3713
US

IV. Provider business mailing address

1135 S GROVE AVE
OAK PARK IL
60304-1908
US

V. Phone/Fax

Practice location:
  • Phone: 866-434-3255
  • Fax:
Mailing address:
  • Phone: 312-504-3389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. FREDRIC D LEARY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 312-504-3389