MEDICARE: THE MONTROSE MEDICAL GROUP, LLC

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	2083X0100X	Occupational Medicine Physician	036065761	IL
2	207Q00000X	Family Medicine Physician	036065761	IL

General Provider Information

NPI Number	:	1679892889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE MONTROSE MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	4757 W MONTROSE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1504
Country	:	US
Telephone Number	:	773-777-2620
Fax Number	:	773-777-3030

Provider Business Practice Location Address
First Line	:	4757 W MONTROSE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1504
Country	:	US
Telephone Number	:	773-777-2620
Fax Number	:	773-777-3030

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. THEODORE SIDNEY WRIGHT JR.
Credential	:	M.D.
Telephone Number	:	773-777-2620

Provider Enumeration Date	:	05/27/2010
Last Update Date	:	05/27/2010

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