Provider Demographics
NPI:1316017502
Name:PRO HEALTH MEDICAL GROUP
Entity Type:Organization
Organization Name:PRO HEALTH MEDICAL GROUP
Other - Org Name:PRO HEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALKSANDER
Authorized Official - Middle Name:SPANYA
Authorized Official - Last Name:ODISHO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-983-8474
Mailing Address - Street 1:4444 OAKTON ST
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-3259
Mailing Address - Country:US
Mailing Address - Phone:847-983-8474
Mailing Address - Fax:847-983-8832
Practice Address - Street 1:4444 OAKTON ST
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-3259
Practice Address - Country:US
Practice Address - Phone:847-983-8474
Practice Address - Fax:847-983-8832
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRO HEALTH MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-08
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211301Medicare ID - Type UnspecifiedGROUP PROVIDER #