Healthcare Provider Details

I. General information

NPI: 1598081333
Provider Name (Legal Business Name): TRI CARE MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2010
Last Update Date: 04/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4332 N ELSTON AVE
CHICAGO IL
60641-2144
US

IV. Provider business mailing address

1375 E SCHAUMBURG RD STE 100
SCHAUMBURG IL
60194-5166
US

V. Phone/Fax

Practice location:
  • Phone: 847-891-6850
  • Fax: 630-339-5803
Mailing address:
  • Phone: 847-891-6850
  • Fax: 630-339-5803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MOHAMMAD AZHARUDDIN
Title or Position: PRESIDENT
Credential:
Phone: 847-891-6850