Provider Demographics
NPI:1619204625
Name:PEACE MEDICAL GROUP INCORPORATED
Entity Type:Organization
Organization Name:PEACE MEDICAL GROUP INCORPORATED
Other - Org Name:ANUMI MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZENG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-808-0880
Mailing Address - Street 1:PO BOX 167378
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-7378
Mailing Address - Country:US
Mailing Address - Phone:312-808-0880
Mailing Address - Fax:312-808-0840
Practice Address - Street 1:234 W CERMAK RD
Practice Address - Street 2:1ST FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-4879
Practice Address - Country:US
Practice Address - Phone:312-808-0880
Practice Address - Fax:312-808-0840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-11
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036123779261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036123779Medicaid
IL1619204625Medicare UPIN
IL036123779Medicaid