Provider Demographics
NPI:1932221397
Name:AXIS MEDICAL MANAGEMENT GOUP SC
Entity Type:Organization
Organization Name:AXIS MEDICAL MANAGEMENT GOUP SC
Other - Org Name:NEW LIFE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STRUWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-542-1111
Mailing Address - Street 1:4111 W 26TH ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-4313
Mailing Address - Country:US
Mailing Address - Phone:773-542-1111
Mailing Address - Fax:773-542-7100
Practice Address - Street 1:4111 W 26TH ST
Practice Address - Street 2:SUITE 110
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-4313
Practice Address - Country:US
Practice Address - Phone:773-542-1111
Practice Address - Fax:773-542-7100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-05
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042.618397038.010225111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1634898OtherBLUE CROSS BLUE SHIELD ID
ILU98738Medicare UPIN