Healthcare Provider Details

I. General information

NPI: 1154980571
Provider Name (Legal Business Name): SANMISOLA GEORGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 BALLARD RD
PARK RIDGE IL
60068-1005
US

IV. Provider business mailing address

23520 CACTUS AVE
MORENO VALLEY CA
92553-8906
US

V. Phone/Fax

Practice location:
  • Phone: 847-318-6020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036160977
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036160977
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA183488
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: