MEDICARE: ILLINOIS DOCTORS ON DEMAND

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1780148072
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ILLINOIS DOCTORS ON DEMAND

Provider Business Mailing Address
First Line	:	4900 N PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-2813
Country	:	US
Telephone Number	:	847-530-5916
Fax Number	:	773-904-0393

Provider Business Practice Location Address
First Line	:	4900 N PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-2813
Country	:	US
Telephone Number	:	847-530-5916
Fax Number	:	773-904-0393

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DELIA FAMANAS
Credential	:
Telephone Number	:	847-530-5916

Provider Enumeration Date	:	01/30/2019
Last Update Date	:	02/07/2021

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