Healthcare Provider Details

I. General information

NPI: 1366941510
Provider Name (Legal Business Name): OAK BROOK MEDICAL GROUP LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2018
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2603 W 22ND ST STE 22
OAK BROOK IL
60523-4637
US

IV. Provider business mailing address

2603 W 22ND ST STE 22
OAK BROOK IL
60523-4637
US

V. Phone/Fax

Practice location:
  • Phone: 630-317-7478
  • Fax: 630-317-7504
Mailing address:
  • Phone: 630-317-7478
  • Fax: 630-317-7504

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