Provider Demographics
NPI:1235376690
Name:MICHAEL G CLOSE MD PC
Entity Type:Organization
Organization Name:MICHAEL G CLOSE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:MIEDEMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-243-0010
Mailing Address - Street 1:5137 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-3009
Mailing Address - Country:US
Mailing Address - Phone:773-243-0010
Mailing Address - Fax:773-243-0015
Practice Address - Street 1:5137 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-3009
Practice Address - Country:US
Practice Address - Phone:773-243-0010
Practice Address - Fax:773-243-0015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086407207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036086407Medicaid
IL1622969OtherBCBS