Provider Demographics
NPI:1518498393
Name:CERMAK MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:CERMAK MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RUCHIR
Authorized Official - Middle Name:
Authorized Official - Last Name:THAKKAR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:708-222-0100
Mailing Address - Street 1:5741 W CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-2129
Mailing Address - Country:US
Mailing Address - Phone:708-222-0100
Mailing Address - Fax:708-222-0102
Practice Address - Street 1:5741 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2129
Practice Address - Country:US
Practice Address - Phone:708-222-0100
Practice Address - Fax:708-222-0102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-23
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036133879207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036133879Medicaid
ILF400175574Medicare PIN