Provider Demographics
NPI:1710309703
Name:CMG FAMILY WELLNESS CENTER
Entity Type:Organization
Organization Name:CMG FAMILY WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:
Authorized Official - First Name:GEORGIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:PANGALLO
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:708-393-7533
Mailing Address - Street 1:6948 WINDSOR AVE.
Mailing Address - Street 2:
Mailing Address - City:BERVYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3335
Mailing Address - Country:US
Mailing Address - Phone:708-393-7533
Mailing Address - Fax:708-394-0911
Practice Address - Street 1:198 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-2323
Practice Address - Country:US
Practice Address - Phone:708-393-7538
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty