Healthcare Provider Details

I. General information

NPI: 1417992306
Provider Name (Legal Business Name): WESTERN SPRINGS FAMILY PRACTICE CENTER, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 12/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5600 WOLF RD
WESTERN SPRINGS IL
60558-2254
US

IV. Provider business mailing address

5600 WOLF RD SUITE 140
WESTERN SPRINGS IL
60558-2254
US

V. Phone/Fax

Practice location:
  • Phone: 708-246-7222
  • Fax:
Mailing address:
  • Phone: 708-246-7222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number42005694
License Number StateIL

VIII. Authorized Official

Name: KAREN RODGERS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 708-246-7222