Provider Demographics
NPI:1285216242
Name:MD FAMILY MEDICAL PRACTICE LLC
Entity Type:Organization
Organization Name:MD FAMILY MEDICAL PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DNP
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DERYLO
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:847-975-6263
Mailing Address - Street 1:1924 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-5020
Mailing Address - Country:US
Mailing Address - Phone:847-975-6263
Mailing Address - Fax:888-907-8030
Practice Address - Street 1:7425 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-2139
Practice Address - Country:US
Practice Address - Phone:847-975-6263
Practice Address - Fax:888-907-8030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care