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General NPI Number Information
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NPI Number | 1700066453
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Entity Type | Organization
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Legal Business Name | NORTHWEST MEDICAL ASSOCIATES, SC
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Dates
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Enumeration Date | 11/10/2007
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Last Update Date | 02/22/2014
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Provider Practice Location Address
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Address Line | 30 E 15TH ST SUITE 310
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City | CHICAGO HEIGHTS
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State | IL
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Zip | 60411-3459
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Country | US
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Telephone | 708-754-3225
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Fax |
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Provider Business Mailing Address
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Address Line | 30 E 15TH ST SUITE 310
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City | CHICAGO HEIGHTS
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State | IL
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Zip | 60411-3459
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Country | US
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Telephone | 708-754-3225
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Fax |
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Authorized Official
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Title or Position | SOLE OWNER
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Name | CHARLOTTE MITCHELL
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Credential | M.D.
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Telephone | 708-754-3225
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 036079491
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License Number State | IL
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