Provider Demographics
NPI:1649219007
Name:ILLINOIS MEDICAL GROUP SC
Entity Type:Organization
Organization Name:ILLINOIS MEDICAL GROUP SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SARMED
Authorized Official - Middle Name:G
Authorized Official - Last Name:ELIAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-545-6900
Mailing Address - Street 1:4211 N CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-1651
Mailing Address - Country:US
Mailing Address - Phone:773-545-6900
Mailing Address - Fax:773-685-2481
Practice Address - Street 1:4211 N CICERO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-1651
Practice Address - Country:US
Practice Address - Phone:773-545-6900
Practice Address - Fax:773-685-2481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042618822261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDG1734OtherMEDICARE RAILROAD
IL213734Medicare PIN