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General NPI Number Information
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NPI Number | 1396946695
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Entity Type | Organization
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Legal Business Name | EVERGREEN MEDICAL GROUP SC
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Dates
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Enumeration Date | 05/31/2007
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Last Update Date | 02/18/2010
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Provider Practice Location Address
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Address Line | 2000 MCDONALD RD SUITE 220
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City | SOUTH ELGIN
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State | IL
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Zip | 60177-3323
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Country | US
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Telephone | 847-468-1206
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Fax | 847-468-1507
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Provider Business Mailing Address
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Address Line | PO BOX 1509
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City | ELGIN
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State | IL
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Zip | 60121-1509
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Country | US
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Telephone | 224-238-4160
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Fax | 847-214-9489
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Authorized Official
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Title or Position | DIRECTOR
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Name | MICHELLE M SEO
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Credential | MD
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Telephone | 847-468-1206
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 036090073
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License Number State | IL
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