Provider Demographics
NPI:1538265616
Name:ERT FAMILY PRACTICE, S.C
Entity type:Organization
Organization Name:ERT FAMILY PRACTICE, S.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BARDACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-915-4019
Mailing Address - Street 1:4828 LINSCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-3539
Mailing Address - Country:US
Mailing Address - Phone:630-915-4019
Mailing Address - Fax:
Practice Address - Street 1:2000 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7222
Practice Address - Country:US
Practice Address - Phone:630-978-4810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL109696207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH48185Medicare UPIN
IL212183Medicare ID - Type Unspecified