=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558788760
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE GATE PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2014
-----------------------------------------------------
Last Update Date | 09/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5241 S CICERO AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-557-3155
-----------------------------------------------------
Fax | 773-284-6431
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8559 W 121ST ST
-----------------------------------------------------
City | PALOS PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60464-1230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-557-3155
-----------------------------------------------------
Fax | 727-474-9067
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. MICHELLE HERZOG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-557-3155
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 036059796
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 016003225
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------