MEDICARE: PARTNERMD ILLINOIS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1275943508
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARTNERMD ILLINOIS PC

Provider Business Mailing Address
First Line	:	7001 FOREST AVE
Second Line	:	SUITE 302
City	:	RICHMOND
State	:	VA
Zip	:	23230-1726
Country	:	US
Telephone Number	:	804-282-2655
Fax Number	:

Provider Business Practice Location Address
First Line	:	2435 DEAN ST
Second Line	:	UNIT C
City	:	ST CHARLES
State	:	IL
Zip	:	60175-4827
Country	:	US
Telephone Number	:	804-282-2655
Fax Number	:

Authorized Official
Title or Position	:	CHIEF MEDICAL OFFICER
Name	:	JAMES MUMPER
Credential	:	MD
Telephone Number	:	804-282-2655

Provider Enumeration Date	:	05/08/2014
Last Update Date	:	05/08/2014

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