Healthcare Provider Details

I. General information

NPI: 1467405985
Provider Name (Legal Business Name): MIDWEST PHYSICIAN GROUP LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 12/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20110 GOVERNORS HWY SUITE 1
OLYMPIA FIELDS IL
60461-1030
US

IV. Provider business mailing address

20110 GOVERNORS HWY SUITE 1
OLYMPIA FIELDS IL
60461-1030
US

V. Phone/Fax

Practice location:
  • Phone: 708-747-7960
  • Fax: 708-503-3993
Mailing address:
  • Phone: 708-747-7960
  • Fax: 708-503-3993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number42005377
License Number StateIL

VIII. Authorized Official

Name: MR. DEBORAH J NELSON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 708-747-7960