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General NPI Number Information
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NPI Number | 1538265616
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Entity Type | Organization
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Legal Business Name | ERT FAMILY PRACTICE, S.C
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Dates
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Enumeration Date | 09/15/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2000 OGDEN AVE
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City | AURORA
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State | IL
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Zip | 60504-7222
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Country | US
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Telephone | 630-978-4810
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Fax |
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Provider Business Mailing Address
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Address Line | 4828 LINSCOTT AVE
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City | DOWNERS GROVE
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State | IL
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Zip | 60515-3539
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Country | US
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Telephone | 630-915-4019
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHELLE ANN BARDACK
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Credential | MD
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Telephone | 630-915-4019
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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 | 109696
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License Number State | IL
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