Provider Demographics
NPI:1801476502
Name:PRESTIGE MEDICAL GROUP LLC
Entity type:Organization
Organization Name:PRESTIGE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:SKOBEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-942-6843
Mailing Address - Street 1:300 N VINE ST UNIT 614
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-5032
Mailing Address - Country:US
Mailing Address - Phone:708-942-6843
Mailing Address - Fax:
Practice Address - Street 1:8800 W 159TH ST
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-5618
Practice Address - Country:US
Practice Address - Phone:708-942-6843
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-08
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No291U00000XLaboratoriesClinical Medical Laboratory