Provider Demographics
NPI:1790777837
Name:ASKLEPIOS MEDICAL GROUP LTD
Entity Type:Organization
Organization Name:ASKLEPIOS MEDICAL GROUP LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF MEDICAL GROUP PRACTICE
Authorized Official - Prefix:
Authorized Official - First Name:SOTERIOS
Authorized Official - Middle Name:G
Authorized Official - Last Name:POLYCHRONOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-445-2422
Mailing Address - Street 1:11638 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-4730
Mailing Address - Country:US
Mailing Address - Phone:773-445-2422
Mailing Address - Fax:773-445-5182
Practice Address - Street 1:11638 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-4730
Practice Address - Country:US
Practice Address - Phone:773-445-2422
Practice Address - Fax:773-445-5182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL110019213OtherRAILROAD
IL31602250OtherBCBS
IL036051757Medicaid
IL777470Medicare ID - Type Unspecified