1740359876 NPI number — MOKENA FAMILY PHYSICIANS LLC

Table of content: (NPI 1740359876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740359876 NPI number — MOKENA FAMILY PHYSICIANS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOKENA FAMILY PHYSICIANS LLC
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:
1740359876
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11243 W LA PORTE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOKENA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60448-1374
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-479-4681
Provider Business Mailing Address Fax Number:
708-479-8516

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11243 W LA PORTE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOKENA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60448-1374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-479-4681
Provider Business Practice Location Address Fax Number:
708-479-8516
Provider Enumeration Date:
11/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
RHONDA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
708-479-4681

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  036085722 , 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: 036085722 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036077425 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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