Provider Demographics
NPI:1467405985
Name:MIDWEST PHYSICIAN GROUP LTD.
Entity Type:Organization
Organization Name:MIDWEST PHYSICIAN GROUP LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:J
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-747-7960
Mailing Address - Street 1:20110 GOVERNORS HWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1030
Mailing Address - Country:US
Mailing Address - Phone:708-747-7960
Mailing Address - Fax:708-503-3993
Practice Address - Street 1:20110 GOVERNORS HWY
Practice Address - Street 2:SUITE 1
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1030
Practice Address - Country:US
Practice Address - Phone:708-747-7960
Practice Address - Fax:708-503-3993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL42005377207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCA1946OtherRAILROAD MEDICARE GROUP
ILCA7850OtherRAILROAD MEDICARE GROUP
ILCD4066OtherRAILROAD MEDICARE GROUP
ILC10237OtherRAILROAD MEDICARE GROUP
IL0001616617OtherBLUE SHIELD ID
ILCC6202OtherRAILROAD MEDICARE GROUP
IL634816Medicare ID - Type Unspecified
ILC10237OtherRAILROAD MEDICARE GROUP
IL992729Medicare ID - Type Unspecified
IL360090Medicare ID - Type Unspecified
ILCA7850OtherRAILROAD MEDICARE GROUP
IL634815Medicare ID - Type Unspecified
IL634813Medicare ID - Type Unspecified
IL992724Medicare ID - Type Unspecified
IL992725Medicare ID - Type Unspecified
IL992722Medicare ID - Type Unspecified
IL634811Medicare ID - Type Unspecified