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General NPI Number Information
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NPI Number | 1679892889
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Entity Type | Organization
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Legal Business Name | THE MONTROSE MEDICAL GROUP, LLC
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Dates
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Enumeration Date | 05/27/2010
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Last Update Date | 05/27/2010
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Provider Practice Location Address
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Address Line | 4757 W MONTROSE AVE
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City | CHICAGO
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State | IL
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Zip | 60641-1504
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Country | US
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Telephone | 773-777-2620
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Fax | 773-777-3030
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Provider Business Mailing Address
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Address Line | 4757 W MONTROSE AVE
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City | CHICAGO
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State | IL
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Zip | 60641-1504
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Country | US
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Telephone | 773-777-2620
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Fax | 773-777-3030
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. THEODORE SIDNEY WRIGHT JR.
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Credential | M.D.
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Telephone | 773-777-2620
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2083X0100X
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Taxonomy Name | Occupational Medicine Physician
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License Number | 036065761
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036065761
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License Number State | IL
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