Provider Demographics
NPI:1932141579
Name:FAMILY MEDICAL GROUP, S.C
Entity Type:Organization
Organization Name:FAMILY MEDICAL GROUP, S.C
Other - Org Name:FAMILY MEDICAL GROUP,S.C
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FAMILY PRACTICE M.D
Authorized Official - Prefix:
Authorized Official - First Name:MICHALE
Authorized Official - Middle Name:
Authorized Official - Last Name:WASZAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-725-3440
Mailing Address - Street 1:330 MADISON ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6565
Mailing Address - Country:US
Mailing Address - Phone:815-725-3440
Mailing Address - Fax:815-725-7209
Practice Address - Street 1:330 MADISON ST
Practice Address - Street 2:SUITE 104
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6565
Practice Address - Country:US
Practice Address - Phone:815-725-3440
Practice Address - Fax:815-725-7209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherGROUP TAX ID