Healthcare Provider Details

I. General information

NPI: 1336170844
Provider Name (Legal Business Name): OLYMPIA FIELDS INTERNAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 04/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19550 S GOVERNORS HIGHWAY STE 2000
FLOSSMOOR IL
60422-2136
US

IV. Provider business mailing address

19550 S GOVERNORS HIGHWAY STE 2000
FLOSSMOOR IL
60422-2136
US

V. Phone/Fax

Practice location:
  • Phone: 708-957-8750
  • Fax: 708-957-8602
Mailing address:
  • Phone: 708-957-8750
  • Fax: 708-957-8602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. LOIS A GLASGOW
Title or Position: AGENT OF RECORD PRESIDENT
Credential:
Phone: 708-957-8750