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General NPI Number Information
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NPI Number | 1245237460
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Entity Type | Organization
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Legal Business Name | EVERGREEN MEDICAL, LTD.
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Dates
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Enumeration Date | 07/01/2005
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Last Update Date | 03/22/2018
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Provider Practice Location Address
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Address Line | 2850 W 95TH ST SUITE 403
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City | EVERGREEN PARK
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State | IL
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Zip | 60805-2735
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Country | US
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Telephone | 708-423-2662
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Fax | 708-422-7264
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Provider Business Mailing Address
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Address Line | 2850 W 95TH ST SUITE 403
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City | EVERGREEN PARK
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State | IL
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Zip | 60805-2735
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Country | US
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Telephone | 708-423-2662
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Fax | 708-422-7264
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOHN R ELSEN
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Credential | M.D.
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Telephone | 708-423-2662
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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 | 042-618475
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License Number State | IL
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