# FAMILY MEDICAL GROUP OF LAGRANGE

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1609806421
- **Authorized official:** OLGA BARTOLOMEO (MANAGER)
- **Authorized official phone:** (708) 579-9375

## Contact information

- **Practice address:** 1415 W 47TH ST, LA GRANGE, IL 60525-6136
- **Practice address phone:** (708) 579-9375
- **Practice address fax:** (708) 579-9378
- **Mailing address:** 1415 W 47TH ST, LA GRANGE, IL 60525-6136
- **Mailing address phone:** (708) 579-9375
- **Mailing address fax:** (708) 579-9378

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 302F00000X | Exclusive Provider Organization | — | NULL | Yes |

## Other

- **Enumeration date:** 07/04/2006
- **Last updated:** 12/11/2007

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 521400 | MEDICARE GROUP | IL |