Provider Demographics
NPI:1649203092
Name:KORLE BU MEDICAL GROUP
Entity Type:Organization
Organization Name:KORLE BU MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ACQUAYE-AWAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-643-0400
Mailing Address - Street 1:9033 RESERVE DR
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60480-1655
Mailing Address - Country:US
Mailing Address - Phone:773-643-0400
Mailing Address - Fax:773-643-0640
Practice Address - Street 1:5517 S. ELLIS AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637
Practice Address - Country:US
Practice Address - Phone:773-643-0400
Practice Address - Fax:773-643-0640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Not Answered183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Not Answered213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209015Medicare ID - Type Unspecified