Provider Demographics
NPI:1437251253
Name:ADVANCED MEDICAL GROUP, LTD.
Entity Type:Organization
Organization Name:ADVANCED MEDICAL GROUP, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:POTHEKIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-465-9311
Mailing Address - Street 1:145 W DUNDEE RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-3706
Mailing Address - Country:US
Mailing Address - Phone:847-465-9311
Mailing Address - Fax:847-465-8233
Practice Address - Street 1:145 W DUNDEE RD
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-3706
Practice Address - Country:US
Practice Address - Phone:847-465-9311
Practice Address - Fax:847-465-8233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36033558174400000X
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1633589OtherBCBS #
IL1633589OtherBCBS #