Healthcare Provider Details

I. General information

NPI: 1447356696
Provider Name (Legal Business Name): GOLF MILL MEDICAL CENTER LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 02/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7124 W TOUHY AVE
NILES IL
60714-4526
US

IV. Provider business mailing address

7124 W TOUHY AVE
NILES IL
60714-4526
US

V. Phone/Fax

Practice location:
  • Phone: 847-983-8695
  • Fax: 847-972-1926
Mailing address:
  • Phone: 847-983-8695
  • Fax: 847-972-1926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036083674
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036093705
License Number StateIL

VIII. Authorized Official

Name: DR. EDWARD E HERNAEZ
Title or Position: MD
Credential: MD
Phone: 847-983-8695