Provider Demographics
NPI:1013193283
Name:MIDWEST ENVIRONMENTAL MEDICINE PC
Entity Type:Organization
Organization Name:MIDWEST ENVIRONMENTAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:C
Authorized Official - Last Name:MOISAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-448-1400
Mailing Address - Street 1:10660 W 143RD ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-1982
Mailing Address - Country:US
Mailing Address - Phone:708-349-0055
Mailing Address - Fax:708-460-8031
Practice Address - Street 1:12255 S 80TH AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1270
Practice Address - Country:US
Practice Address - Phone:708-448-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty