Provider Demographics
NPI:1093208449
Name:CYBER MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:CYBER MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-215-4419
Mailing Address - Street 1:5067 N LINCOLN AVE APT 201
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-8188
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5067 N LINCOLN AVE APT 201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-8188
Practice Address - Country:US
Practice Address - Phone:414-215-4419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty