1497742860 NPI number — CHARLES G GROEN MD

Table of content: CHARLES G GROEN MD (NPI 1497742860)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497742860 NPI number — CHARLES G GROEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROEN
Provider First Name:
CHARLES
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1497742860
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3610 PAYSPHERE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60674-0036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-585-7000
Provider Business Mailing Address Fax Number:
847-240-0622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8915 W GOLF RD
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
NILES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60714-5905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-827-9490
Provider Business Practice Location Address Fax Number:
847-827-2241
Provider Enumeration Date:
09/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  036085244 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: 01068054A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000726585 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 036085244 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201034800 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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