Provider Demographics
NPI:1780715292
Name:CARY GROVE MEDICAL ASSOCIATES, S.C.
Entity type:Organization
Organization Name:CARY GROVE MEDICAL ASSOCIATES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SOL
Authorized Official - Middle Name:BICOMONG
Authorized Official - Last Name:DAYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-444-1913
Mailing Address - Street 1:7105 N. VIRGINIA ROAD
Mailing Address - Street 2:UNIT 7
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7986
Mailing Address - Country:US
Mailing Address - Phone:815-444-1913
Mailing Address - Fax:815-444-1951
Practice Address - Street 1:7105 VIRGINIA RD STE 7
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7986
Practice Address - Country:US
Practice Address - Phone:815-444-1913
Practice Address - Fax:815-444-1951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL962220Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
ILD88995Medicare UPIN