1881107902 NPI number — NORTHWEST MEDICAL AND URGENT CARE CENTER AT MADISON LTD

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 1881107902 NPI number — NORTHWEST MEDICAL AND URGENT CARE CENTER AT MADISON LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST MEDICAL AND URGENT CARE CENTER AT MADISON LTD
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:
1881107902
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5352 N LINCOLN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60625-2316
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-353-5047
Provider Business Mailing Address Fax Number:
773-353-2406

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3171 W MADISON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-1809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-362-4648
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/10/2017

Additional Information

Authorized Official

Authorized Official Last Name:
KHAMIS
Authorized Official First Name:
MOHAMMAD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
773-362-4648

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036112029 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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