MEDICARE: MSO GREAT LAKES, INC.

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	302R00000X	Health Maintenance Organization

General Provider Information

NPI Number	:	1538663679
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MSO GREAT LAKES, INC.

Provider Business Mailing Address
First Line	:	5860 W HIGGINS AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-2372
Country	:	US
Telephone Number	:	773-695-4800
Fax Number	:	773-864-9418

Provider Business Practice Location Address
First Line	:	5860 W HIGGINS AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-2372
Country	:	US
Telephone Number	:	773-695-4800
Fax Number	:	773-864-9418

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MS. DARA C ELLINGSON
Credential	:
Telephone Number	:	773-695-4800

Provider Enumeration Date	:	03/22/2018
Last Update Date	:	06/16/2018

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