MEDICARE: ILLINOIS MEDICAL GROUP SC

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	261QM1300X	Multi-Specialty Clinic/Center	042618822	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DG1734	OTHER	IL	MEDICARE RAILROAD

General Provider Information

NPI Number	:	1649219007
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ILLINOIS MEDICAL GROUP SC

Provider Business Mailing Address
First Line	:	4211 N CICERO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1651
Country	:	US
Telephone Number	:	773-545-6900
Fax Number	:	773-685-2481

Provider Business Practice Location Address
First Line	:	4211 N CICERO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1651
Country	:	US
Telephone Number	:	773-545-6900
Fax Number	:	773-685-2481

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SARMED G ELIAS
Credential	:	M.D.
Telephone Number	:	773-545-6900

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	06/12/2008

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Directions to “ILLINOIS MEDICAL GROUP SC ” Practice Location

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