Provider Demographics
NPI:1437186954
Name:MERRIONETTE PARK PHYSICIANS GROUP
Entity Type:Organization
Organization Name:MERRIONETTE PARK PHYSICIANS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:COLTRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-422-6800
Mailing Address - Street 1:9830 RIDGELAND AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2667
Mailing Address - Country:US
Mailing Address - Phone:708-422-6800
Mailing Address - Fax:708-422-6888
Practice Address - Street 1:9830 RIDGELAND AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2667
Practice Address - Country:US
Practice Address - Phone:708-422-6800
Practice Address - Fax:708-422-6888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
042617755207R00000X
IL042617755207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty