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General NPI Number Information
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NPI Number | 1962935924
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Entity Type | Organization
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Legal Business Name | PHYSICIAN MANAGEMENT SERVICES OF ILLINOIS, LLC
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Dates
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Enumeration Date | 04/06/2017
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Last Update Date | 09/20/2019
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Provider Practice Location Address
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Address Line | 7900 N MILWAUKEE AVE STE 2-33
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City | NILES
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State | IL
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Zip | 60714-3240
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Country | US
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Telephone | 888-829-8550
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Fax |
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Provider Business Mailing Address
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Address Line | 3113 LAWTON RD STE 250
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City | ORLANDO
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State | FL
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Zip | 32803-3517
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Country | US
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Telephone | 888-829-8550
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRETT KENEFICK
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Credential |
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Telephone | 888-829-8550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036.06653
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License Number State | IL
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