Provider Demographics
NPI:1255660312
Name:PALOS MEDICAL GROUP, LLC.
Entity Type:Organization
Organization Name:PALOS MEDICAL GROUP, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:C
Authorized Official - Last Name:MOISAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-923-5000
Mailing Address - Street 1:12251 S 80TH AVE STE 1630
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1256
Mailing Address - Country:US
Mailing Address - Phone:708-923-5173
Mailing Address - Fax:708-923-5018
Practice Address - Street 1:15300 WEST AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4600
Practice Address - Country:US
Practice Address - Phone:708-590-5304
Practice Address - Fax:708-590-5308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-18
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36102101Medicaid