Provider Demographics
NPI:1790976231
Name:MIDWEST PHYSICIAN GROUP LTD
Entity Type:Organization
Organization Name:MIDWEST PHYSICIAN GROUP LTD
Other - Org Name:MARITTA A PENEGOR CFNP
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:J
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-747-7960
Mailing Address - Street 1:20110 GOVERNORS HWY
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1030
Mailing Address - Country:US
Mailing Address - Phone:708-747-7960
Mailing Address - Fax:708-503-3993
Practice Address - Street 1:3800 W 203RD ST
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1184
Practice Address - Country:US
Practice Address - Phone:708-747-0461
Practice Address - Fax:708-747-0607
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDWEST PHYSICIAN GROUP LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-08
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL204683Medicare PIN