Provider Demographics
NPI:1447356696
Name:GOLF MILL MEDICAL CENTER LTD
Entity type:Organization
Organization Name:GOLF MILL MEDICAL CENTER LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:HERNAEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-983-8695
Mailing Address - Street 1:7124 W TOUHY AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-4526
Mailing Address - Country:US
Mailing Address - Phone:847-983-8695
Mailing Address - Fax:847-972-1926
Practice Address - Street 1:7124 W TOUHY AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-4526
Practice Address - Country:US
Practice Address - Phone:847-983-8695
Practice Address - Fax:847-972-1926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093705207Q00000X
IL036083674208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG34901Medicare UPIN
ILL94770Medicare ID - Type Unspecified