Provider Demographics
NPI:1942585468
Name:NGU MD. WELLNESS LTD.
Entity Type:Organization
Organization Name:NGU MD. WELLNESS LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:N
Authorized Official - Last Name:NGU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-250-8424
Mailing Address - Street 1:400 E RANDOLPH ST
Mailing Address - Street 2:APT 2711
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7329
Mailing Address - Country:US
Mailing Address - Phone:708-250-8424
Mailing Address - Fax:
Practice Address - Street 1:400 E RANDOLPH ST
Practice Address - Street 2:APT 2711
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7329
Practice Address - Country:US
Practice Address - Phone:708-250-8424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-15
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092049207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK14846OtherMEDICARE ID TYPE UNSPECIFIED
ILG56795Medicare UPIN