Provider Demographics
NPI:1093812364
Name:SAGE MEDICAL GROUP, SC
Entity Type:Organization
Organization Name:SAGE MEDICAL GROUP, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-549-7757
Mailing Address - Street 1:1150 W FULLERTON AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-8160
Mailing Address - Country:US
Mailing Address - Phone:773-549-7757
Mailing Address - Fax:773-549-1221
Practice Address - Street 1:1150 W FULLERTON AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-8160
Practice Address - Country:US
Practice Address - Phone:773-549-7757
Practice Address - Fax:773-549-1221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL356240Medicare PIN