Provider Demographics
NPI:1245237460
Name:EVERGREEN MEDICAL, LTD.
Entity Type:Organization
Organization Name:EVERGREEN MEDICAL, LTD.
Other - Org Name:EVERGREEN FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:ELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-423-2662
Mailing Address - Street 1:2850 W 95TH ST
Mailing Address - Street 2:SUITE 403
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2735
Mailing Address - Country:US
Mailing Address - Phone:708-423-2662
Mailing Address - Fax:708-422-7264
Practice Address - Street 1:2850 W 95TH ST
Practice Address - Street 2:SUITE 403
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2735
Practice Address - Country:US
Practice Address - Phone:708-423-2662
Practice Address - Fax:708-422-7264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042-618475207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC45863Medicare UPIN
ILK11168Medicare ID - Type UnspecifiedDR. HAMPSTON ID
ILL18660Medicare UPIN
ILF54018Medicare UPIN
ILL70347Medicare ID - Type UnspecifiedDR. HANLON ID
IL43240000Medicare ID - Type UnspecifiedGROUP ID
ILG91401Medicare UPIN
ILL63810Medicare ID - Type UnspecifiedDR. DAUM ID
ILL63808Medicare ID - Type UnspecifiedDR. ELSEN ID