=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841531456
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUSH OAK PARK PHYSICIANS GROUP LAKE STREET
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2013
-----------------------------------------------------
Last Update Date | 09/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1011 LAKE ST SUITE 300
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60301-1148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-628-0600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1011 LAKE ST SUITE 300
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60301-1148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-628-0600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | SCOTT A HALPER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-942-7770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------