Healthcare Provider Details

I. General information

NPI: 1205393972
Provider Name (Legal Business Name): MIDWEST MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2019
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 MIDWEST RD STE LL22
OAK BROOK IL
60523-1316
US

IV. Provider business mailing address

2001 MIDWEST RD STE LL22
OAK BROOK IL
60523-1316
US

V. Phone/Fax

Practice location:
  • Phone: 239-970-2484
  • Fax: 239-228-8640
Mailing address:
  • Phone: 239-970-2484
  • Fax: 239-228-8640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: BARRY WOLF
Title or Position: BILLING MANAGER
Credential: BS
Phone: 239-970-2484