1396768727 NPI number — MAVENA DERMA CENTERS, INC.

Table of content: (NPI 1396768727)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396768727 NPI number — MAVENA DERMA CENTERS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAVENA DERMA CENTERS, INC.
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:
1396768727
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 N. MICHIGAN AVENUE
Provider Second Line Business Mailing Address:
300
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60611-3777
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-298-9400
Provider Business Mailing Address Fax Number:
847-298-7660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 W CENTRAL RD
Provider Second Line Business Practice Location Address:
306
Provider Business Practice Location Address City Name:
ARLINGTON HEIGHTS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60005-2402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-483-9621
Provider Business Practice Location Address Fax Number:
847-483-9625
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCGINNIS
Authorized Official First Name:
JERRI
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
847-483-9621

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01636236 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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