Provider Demographics
NPI:1861670101
Name:NORTHERN ILLINOIS MEDICAL GROUP S. C.
Entity Type:Organization
Organization Name:NORTHERN ILLINOIS MEDICAL GROUP S. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:KONG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-397-8500
Mailing Address - Street 1:5301 E STATE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2388
Mailing Address - Country:US
Mailing Address - Phone:815-397-8500
Mailing Address - Fax:815-397-8588
Practice Address - Street 1:5301 E STATE ST STE 101
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2388
Practice Address - Country:US
Practice Address - Phone:815-397-8500
Practice Address - Fax:815-397-8588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-08
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X, 207L00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPTAN216879Medicare PIN