Provider Demographics
NPI:1609806421
Name:FAMILY MEDICAL GROUP OF LAGRANGE
Entity Type:Organization
Organization Name:FAMILY MEDICAL GROUP OF LAGRANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTOLOMEO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-579-9375
Mailing Address - Street 1:1415 W 47TH ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6136
Mailing Address - Country:US
Mailing Address - Phone:708-579-9375
Mailing Address - Fax:708-579-9378
Practice Address - Street 1:1415 W 47TH ST
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-6136
Practice Address - Country:US
Practice Address - Phone:708-579-9375
Practice Address - Fax:708-579-9378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL521400OtherMEDICARE GROUP
ILL67024Medicare PIN
ILD12904Medicare UPIN
ILF81268Medicare UPIN
ILI42307Medicare UPIN
IL521400OtherMEDICARE GROUP
ILL67025Medicare PIN