1447291547 NPI number — MONROE MEDICAL ASSOCIATES, SC

Table of content: (NPI 1447291547)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447291547 NPI number — MONROE MEDICAL ASSOCIATES, SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONROE MEDICAL ASSOCIATES, SC
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:
1447291547
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 MACARTHUR BLVD
Provider Second Line Business Mailing Address:
SUITE 401
Provider Business Mailing Address City Name:
MUNSTER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46321-2915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-836-2860
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
71 W 156TH ST
Provider Second Line Business Practice Location Address:
SUITE 401
Provider Business Practice Location Address City Name:
HARVEY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60426-4260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-339-4800
Provider Business Practice Location Address Fax Number:
708-339-4814
Provider Enumeration Date:
06/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KOZLOFF
Authorized Official First Name:
MARK
Authorized Official Middle Name:
F
Authorized Official Title or Position:
CEO / SENIOR PARTNER
Authorized Official Telephone Number:
708-339-4800

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  042003867 , 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: 105630 . This is a "ANTHEM B S GRP PROV #" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 042003867 . This is a "IL REG MED CORP #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1615180 . This is a "B C B S GROUP PROV #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 100394430 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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