Provider Demographics
NPI:1639455173
Name:RUSH-COPLEY MEDICAL GROUP NFP
Entity Type:Organization
Organization Name:RUSH-COPLEY MEDICAL GROUP NFP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCEE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRUMMEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-978-4915
Mailing Address - Street 1:1256 WATERFORD DR STE 230
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-4511
Mailing Address - Country:US
Mailing Address - Phone:630-499-2404
Mailing Address - Fax:630-692-5518
Practice Address - Street 1:2040 OGDEN AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7206
Practice Address - Country:US
Practice Address - Phone:630-499-2329
Practice Address - Fax:630-898-5837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-28
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-115418207Q00000X, 207QA0000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-115418Medicaid