Provider Demographics
NPI:1982624763
Name:ERICKSON HEALTH MEDICAL GROUP OF ILLINOIS PC
Entity Type:Organization
Organization Name:ERICKSON HEALTH MEDICAL GROUP OF ILLINOIS PC
Other - Org Name:SEDGEBROOK MEDICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE VP, CMO
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:NARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-402-2257
Mailing Address - Street 1:701 MAIDEN CHOICE LN
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-5968
Mailing Address - Country:US
Mailing Address - Phone:410-402-2257
Mailing Address - Fax:410-402-2264
Practice Address - Street 1:800 AUDUBON WAY
Practice Address - Street 2:
Practice Address - City:LINCOLNSHIRE
Practice Address - State:IL
Practice Address - Zip Code:60069-3811
Practice Address - Country:US
Practice Address - Phone:847-876-2200
Practice Address - Fax:847-793-0281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontologyGroup - Multi-Specialty
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4932996OtherBCBS OF IL
212238Medicare PIN
DG0867Medicare PIN