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General NPI Number Information
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NPI Number | 1184672966
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Entity Type | Organization
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Legal Business Name | PORTAGE PARK MEDICAL GROUP
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Dates
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Enumeration Date | 05/04/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3401 N CENTRAL AVE
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City | CHICAGO
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State | IL
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Zip | 60634-4426
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Country | US
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Telephone | 773-286-8822
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Fax | 773-824-4997
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Provider Business Mailing Address
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Address Line | 3401 N CENTRAL AVE
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City | CHICAGO
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State | IL
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Zip | 60634-4426
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Country | US
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Telephone | 773-286-8822
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Fax | 773-824-4997
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Authorized Official
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Title or Position | DIRECTOR
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Name | RICHARD ANSFIELD
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Credential |
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Telephone | 773-286-8822
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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