1497837009 NPI number — 29 E MADISON CORP

Table of content: (NPI 1497837009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497837009 NPI number — 29 E MADISON CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
29 E MADISON CORP
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:
IVAN T MATTHEI PHARMACY
Provider Other Organization Name Type Code:
3
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:
1497837009
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 E WASHINGTON ST LOWR 53
Provider Second Line Business Mailing Address:
LOWER LEVEL PEDWAY
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60602-1736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-263-7194
Provider Business Mailing Address Fax Number:
312-263-7636

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 E WASHINGTON ST LOWR 53
Provider Second Line Business Practice Location Address:
LOWER LEVEL PEDWAY
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60602-1736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-263-7194
Provider Business Practice Location Address Fax Number:
312-263-7636
Provider Enumeration Date:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EDELHEIT
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
312-263-7194

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  054013583 , 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: 6060201 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1449948 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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