Provider Demographics
NPI:1447310479
Name:GREENLEAF MEDICAL ASSOCIATES S.C.
Entity type:Organization
Organization Name:GREENLEAF MEDICAL ASSOCIATES S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTHONY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-662-0977
Mailing Address - Street 1:401 GREENLEAF AVE
Mailing Address - Street 2:1
Mailing Address - City:PARK CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60085-5744
Mailing Address - Country:US
Mailing Address - Phone:847-662-0978
Mailing Address - Fax:847-662-1395
Practice Address - Street 1:401 GREENLEAF AVE
Practice Address - Street 2:1
Practice Address - City:PARK CITY
Practice Address - State:IL
Practice Address - Zip Code:60085-5744
Practice Address - Country:US
Practice Address - Phone:847-662-0978
Practice Address - Fax:847-662-1395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX IDENTIFICATION
IL=========OtherTAX IDENTIFICATION