Organization
FAMILY MEDICAL GROUP OF LAGRANGE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
OLGA BARTOLOMEO (MANAGER)
(708) 579-9375
Entity
Organization
Contact information
Practice address
1415 W 47TH ST, LA GRANGE, IL 60525-6136
(708) 579-9375
(708) 579-9378
Mailing address
1415 W 47TH ST, LA GRANGE, IL 60525-6136
(708) 579-9375
(708) 579-9378
Taxonomy
Speciality
Code
Description
License number
State
302F00000X
Exclusive Provider Organization
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
521400
MEDICARE GROUP
IL
Enumeration date
07/04/2006
Last updated
12/11/2007
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