Healthcare Provider Details

I. General information

NPI: 1467672576
Provider Name (Legal Business Name): FAMILY MEDICAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2007
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 BIESTERFIELD RD SUITE 535
ELK GROVE VLG IL
60007-3311
US

IV. Provider business mailing address

800 BIESTERFIELD RD SUITE 535
ELK GROVE VLG IL
60007-3311
US

V. Phone/Fax

Practice location:
  • Phone: 847-439-6803
  • Fax: 847-439-8057
Mailing address:
  • Phone: 847-439-6803
  • Fax: 847-439-8057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036094399
License Number StateIL

VIII. Authorized Official

Name: ROBERTO P CASTRO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 847-439-6803