Provider Demographics
NPI:1508995762
Name:TDK FAMILY MEDICAL CENTERS LLC
Entity Type:Organization
Organization Name:TDK FAMILY MEDICAL CENTERS LLC
Other - Org Name:PRAIRIE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:708-562-5430
Mailing Address - Street 1:2434 WOLF RD
Mailing Address - Street 2:
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-5634
Mailing Address - Country:US
Mailing Address - Phone:708-562-5430
Mailing Address - Fax:708-562-8330
Practice Address - Street 1:2434 WOLF RD
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-5634
Practice Address - Country:US
Practice Address - Phone:708-562-5430
Practice Address - Fax:708-562-8330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL553190Medicare ID - Type UnspecifiedMEDICARE NUMBER