1093021917 NPI number — MARIUS O MOKWE MD.SC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093021917 NPI number — MARIUS O MOKWE MD.SC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIUS O MOKWE MD.SC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093021917
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 CENTER ST
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
ELGIN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60120-2104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-695-7320
Provider Business Mailing Address Fax Number:
847-695-7732

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 CENTER ST
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
ELGIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60120-2104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-695-7320
Provider Business Practice Location Address Fax Number:
847-695-7732
Provider Enumeration Date:
08/30/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOKWE
Authorized Official First Name:
MARIUS
Authorized Official Middle Name:
OBIESIE
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
847-695-7320

Provider Taxonomy Codes

  • Taxonomy code: 207RH0000X , with the licence number:  036094619 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110221774 . This is a "PALMETO GBO" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036094619 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12121881 . This is a "ONE HEALTH PLAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0004525452 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 7953002 . This is a "AETNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".