1790928893 NPI number — ALPHA MED PHYSICIANS GROUP, LLC

Table of content: (NPI 1790928893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790928893 NPI number — ALPHA MED PHYSICIANS GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALPHA MED PHYSICIANS GROUP, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790928893
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17901 GOVERNORS HWY
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
HOMEWOOD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60430-1144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-957-2100
Provider Business Mailing Address Fax Number:
708-957-8044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17901 GOVERNORS HWY
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
HOMEWOOD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60430-1144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-957-2100
Provider Business Practice Location Address Fax Number:
708-957-8044
Provider Enumeration Date:
04/20/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HAMADEH
Authorized Official First Name:
M . MUFFADDAL
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
708-957-2100

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)