Provider Demographics
NPI:1760587703
Name:ST ANTHONY EMERGENCY SERVICES PHYSICIAN GROUP
Entity Type:Organization
Organization Name:ST ANTHONY EMERGENCY SERVICES PHYSICIAN GROUP
Other - Org Name:ST ANTHONY EMERGENCY SERVICES PHYSICIAN GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO, AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:GUY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MEDAGLIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-484-1000
Mailing Address - Street 1:2001 S CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-2486
Mailing Address - Country:US
Mailing Address - Phone:773-484-4783
Mailing Address - Fax:
Practice Address - Street 1:2875 W 19TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-3501
Practice Address - Country:US
Practice Address - Phone:773-484-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAINT ANTHONY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-14
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209966Medicare ID - Type Unspecified