=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609297266
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ULTIMATE MEDICAL GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2013
-----------------------------------------------------
Last Update Date | 02/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3590 HOBSON RD SUITE 301
-----------------------------------------------------
City | WOODRIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60517-5409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-778-9000
-----------------------------------------------------
Fax | 630-778-9065
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3590 HOBSON RD SUITE 301
-----------------------------------------------------
City | WOODRIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60517-5409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-778-9000
-----------------------------------------------------
Fax | 630-778-9065
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. PERRY CAMMISA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-817-6000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038006843
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 03607713
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | 036089214
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036134622
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------