Provider Demographics
NPI:1366726283
Name:COUNTRYSIDE MEDICAL SC
Entity type:Organization
Organization Name:COUNTRYSIDE MEDICAL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-767-3822
Mailing Address - Street 1:PO BOX 700
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-0700
Mailing Address - Country:US
Mailing Address - Phone:773-767-3822
Mailing Address - Fax:773-337-9106
Practice Address - Street 1:6555 S WILLOW SPRINGS RD
Practice Address - Street 2:SUITES 1 & 2
Practice Address - City:COUNTRYSIDE
Practice Address - State:IL
Practice Address - Zip Code:60525
Practice Address - Country:US
Practice Address - Phone:708-482-9700
Practice Address - Fax:708-482-0217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty