Healthcare Provider Details

I. General information

NPI: 1245237460
Provider Name (Legal Business Name): EVERGREEN MEDICAL, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 W 95TH ST SUITE 403
EVERGREEN PARK IL
60805-2735
US

IV. Provider business mailing address

2850 W 95TH ST SUITE 403
EVERGREEN PARK IL
60805-2735
US

V. Phone/Fax

Practice location:
  • Phone: 708-423-2662
  • Fax: 708-422-7264
Mailing address:
  • Phone: 708-423-2662
  • Fax: 708-422-7264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042-618475
License Number StateIL

VIII. Authorized Official

Name: JOHN R ELSEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 708-423-2662