Provider Demographics
NPI:1467672576
Name:FAMILY MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:FAMILY MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:P
Authorized Official - Last Name:CASTRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-439-6803
Mailing Address - Street 1:800 BIESTERFIELD RD
Mailing Address - Street 2:SUITE 535
Mailing Address - City:ELK GROVE VLG
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3311
Mailing Address - Country:US
Mailing Address - Phone:847-439-6803
Mailing Address - Fax:847-439-8057
Practice Address - Street 1:800 BIESTERFIELD RD
Practice Address - Street 2:SUITE 535
Practice Address - City:ELK GROVE VLG
Practice Address - State:IL
Practice Address - Zip Code:60007-3311
Practice Address - Country:US
Practice Address - Phone:847-439-6803
Practice Address - Fax:847-439-8057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094399207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G61968Medicare UPIN
213707Medicare ID - Type Unspecified