Healthcare Provider Details

I. General information

NPI: 1366726283
Provider Name (Legal Business Name): COUNTRYSIDE MEDICAL SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6555 S WILLOW SPRINGS RD SUITES 1 & 2
COUNTRYSIDE IL
60525
US

IV. Provider business mailing address

PO BOX 700
WHEATON IL
60187-0700
US

V. Phone/Fax

Practice location:
  • Phone: 708-482-9700
  • Fax: 708-482-0217
Mailing address:
  • Phone: 773-767-3822
  • Fax: 773-337-9106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0
License Number StateIL

VIII. Authorized Official

Name: LYNNETTE MCROY
Title or Position: BILLING COORDINATOR
Credential:
Phone: 773-767-3822