Organization
EVERGREEN MEDICAL GROUP SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICHELLE M SEO MD (DIRECTOR)
(847) 468-1206
Entity
Organization
Contact information
Practice address
2000 MCDONALD RD, SUITE 220, SOUTH ELGIN, IL 60177-3323
(847) 468-1206
(847) 468-1507
Mailing address
PO BOX 1509, ELGIN, IL 60121-1509
(224) 238-4160
(847) 214-9489
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
036090073
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0004532435
BLUE CROSS BLUE SHIELD
IL
Enumeration date
05/31/2007
Last updated
02/18/2010
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