Provider Demographics
NPI:1033121421
Name:HERITAGE MEDICAL GROUP LTD
Entity Type:Organization
Organization Name:HERITAGE MEDICAL GROUP LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:N
Authorized Official - Last Name:STAVRAKOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-499-3676
Mailing Address - Street 1:5660 W 95TH ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2380
Mailing Address - Country:US
Mailing Address - Phone:708-499-3676
Mailing Address - Fax:708-499-1792
Practice Address - Street 1:5660 W 95TH ST
Practice Address - Street 2:SUITE 6
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2380
Practice Address - Country:US
Practice Address - Phone:708-499-3676
Practice Address - Fax:708-499-1792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1617593OtherBLUECROSSBLUESHIELD
ILCM1337OtherMEDICARERR
IL1617593OtherBLUECROSSBLUESHIELD
ILCM1337OtherMEDICARERR