Provider Demographics
NPI:1245210038
Name:SUBURBAN EMERGENCY PHYSICIANS GROUP, SC
Entity Type:Organization
Organization Name:SUBURBAN EMERGENCY PHYSICIANS GROUP, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-363-1090
Mailing Address - Street 1:6836 S EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-1510
Mailing Address - Country:US
Mailing Address - Phone:773-363-1090
Mailing Address - Fax:773-363-1091
Practice Address - Street 1:6836 S EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-1510
Practice Address - Country:US
Practice Address - Phone:773-363-1090
Practice Address - Fax:773-363-1091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCC2148OtherRAILROAD MEDICARE
ILCC2148OtherRAILROAD MEDICARE