Provider Demographics
NPI:1235162058
Name:MARINE DRIVE MEDICAL GROUP, LTD
Entity Type:Organization
Organization Name:MARINE DRIVE MEDICAL GROUP, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCCREARY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-728-7373
Mailing Address - Street 1:4646 N MARINE DR
Mailing Address - Street 2:#C6300
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5759
Mailing Address - Country:US
Mailing Address - Phone:773-728-7373
Mailing Address - Fax:773-728-3538
Practice Address - Street 1:4646 N MARINE DR
Practice Address - Street 2:#C6300
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5759
Practice Address - Country:US
Practice Address - Phone:773-728-7373
Practice Address - Fax:773-728-3538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01615083OtherBCBS PROVIDER NUMBER
605340Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER