Organization
HERITAGE MEDICAL GROUP LTD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. MARIA N STAVRAKOS (OFFICE MANAGER)
(708) 499-3676
Entity
Organization
Contact information
Practice address
5660 W 95TH ST, SUITE 6, OAK LAWN, IL 60453-2380
(708) 499-3676
(708) 499-1792
Mailing address
5660 W 95TH ST, SUITE 6, OAK LAWN, IL 60453-2380
(708) 499-3676
(708) 499-1792
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1617593
BLUECROSSBLUESHIELD
IL
01
—
CM1337
MEDICARERR
IL
Enumeration date
08/13/2006
Last updated
12/06/2007
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