Provider Demographics
NPI:1962571737
Name:TRAVEL MEDICINE SOURCE LTD
Entity type:Organization
Organization Name:TRAVEL MEDICINE SOURCE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:CATHERINE
Authorized Official - Last Name:MACGREGOR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:847-663-1566
Mailing Address - Street 1:9201 WAUKEGAN RD
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2102
Mailing Address - Country:US
Mailing Address - Phone:847-663-1566
Mailing Address - Fax:847-663-1568
Practice Address - Street 1:9201 WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-2102
Practice Address - Country:US
Practice Address - Phone:847-663-1566
Practice Address - Fax:847-663-1568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036063587Medicaid
IL036063587Medicaid
D15682Medicare UPIN