1235329905 NPI number — MARIUS-NUNEZ MEDICAL GROUP S C

Table of content: (NPI 1235329905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235329905 NPI number — MARIUS-NUNEZ MEDICAL GROUP S C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIUS-NUNEZ MEDICAL GROUP S C
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:
1235329905
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7036 CERMAK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERWYN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60402-2197
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-484-9145
Provider Business Mailing Address Fax Number:
708-484-0441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7036 CERMAK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERWYN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60402-2197
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-484-9145
Provider Business Practice Location Address Fax Number:
708-484-0441
Provider Enumeration Date:
07/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MARIUS
Authorized Official First Name:
ANDRES
Authorized Official Middle Name:
LUIS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
708-484-9145

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  036077902 , 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: 1607253 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036077902 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com