Provider Demographics
NPI:1982974689
Name:RUSH-COPLEY MEDICAL GROUP
Entity type:Organization
Organization Name:RUSH-COPLEY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCEE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRUMMEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-978-4915
Mailing Address - Street 1:1256 WATERFORD DR STE 230
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-4511
Mailing Address - Country:US
Mailing Address - Phone:630-499-2404
Mailing Address - Fax:630-692-5518
Practice Address - Street 1:2040 OGDEN AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7206
Practice Address - Country:US
Practice Address - Phone:630-375-2844
Practice Address - Fax:630-375-2808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-11
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036128969208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036128969Medicaid