MEDICARE: GREATER NORTHWEST MEDICAL GROUP

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		IL

General Provider Information

NPI Number	:	1447280839
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREATER NORTHWEST MEDICAL GROUP

Provider Business Mailing Address
First Line	:	1300 BUSCH PKWY
Second Line	:
City	:	BUFFALO GROVE
State	:	IL
Zip	:	60089-4505
Country	:	US
Telephone Number	:	847-459-7860
Fax Number	:	847-541-5315

Provider Business Practice Location Address
First Line	:	1300 BUSCH PKWY
Second Line	:
City	:	BUFFALO GROVE
State	:	IL
Zip	:	60089-4505
Country	:	US
Telephone Number	:	847-459-7860
Fax Number	:	847-541-5315

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. MICHAEL C HARTKE
Credential	:	MBA
Telephone Number	:	847-459-7860

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	10/10/2007

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