Healthcare Provider Details

I. General information

NPI: 1538663679
Provider Name (Legal Business Name): MSO GREAT LAKES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5860 W HIGGINS AVE
CHICAGO IL
60630-2372
US

IV. Provider business mailing address

5860 W HIGGINS AVE
CHICAGO IL
60630-2372
US

V. Phone/Fax

Practice location:
  • Phone: 773-695-4800
  • Fax: 773-864-9418
Mailing address:
  • Phone: 773-695-4800
  • Fax: 773-864-9418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: MS. DARA C ELLINGSON
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 773-695-4800