Provider Demographics
NPI:1548532351
Name:INDEPENDENT PHYSICIAN GROUP OF ILLINOIS
Entity type:Organization
Organization Name:INDEPENDENT PHYSICIAN GROUP OF ILLINOIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDRIC
Authorized Official - Middle Name:D
Authorized Official - Last Name:LEARY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-504-3389
Mailing Address - Street 1:1135 S GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-1908
Mailing Address - Country:US
Mailing Address - Phone:312-504-3389
Mailing Address - Fax:
Practice Address - Street 1:111 E WACKER DR
Practice Address - Street 2:SUITE 107
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-3713
Practice Address - Country:US
Practice Address - Phone:866-434-3255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QC1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health