Provider Demographics
NPI:1740289354
Name:LA GRANGE WOMEN'S CLINIC SC
Entity type:Organization
Organization Name:LA GRANGE WOMEN'S CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, BOONSLICK MED.GROUP INC
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:FUREY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-352-4630
Mailing Address - Street 1:5201 WILLOW SPRINGS RD
Mailing Address - Street 2:STE 490
Mailing Address - City:LA GRANGE HIGHLANDS
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6537
Mailing Address - Country:US
Mailing Address - Phone:708-352-4630
Mailing Address - Fax:708-352-8348
Practice Address - Street 1:5201 WILLOW SPRINGS RD
Practice Address - Street 2:STE 490
Practice Address - City:LA GRANGE HIGHLANDS
Practice Address - State:IL
Practice Address - Zip Code:60525-6537
Practice Address - Country:US
Practice Address - Phone:708-352-4630
Practice Address - Fax:708-352-8348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL604390Medicare ID - Type Unspecified