1336267855 NPI number — MDM ADVANCED ANCILLARY SERVICES, LLC

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 1336267855 NPI number — MDM ADVANCED ANCILLARY SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MDM ADVANCED ANCILLARY SERVICES, 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:
ADVANCED ANCILLARY SERVICES
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:
1336267855
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPT 10116
Provider Second Line Business Mailing Address:
PO BOX 87618
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60680-0618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-478-6417
Provider Business Mailing Address Fax Number:
708-535-8087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19065 HICKORY CREEK PL
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
MOKENA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60448-8507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-478-6417
Provider Business Practice Location Address Fax Number:
708-535-8087
Provider Enumeration Date:
03/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KNIPPER
Authorized Official First Name:
JON
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
708-478-6434

Provider Taxonomy Codes

  • Taxonomy code: 302F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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