1477521607 NPI number — EDWARD H MKRDICHIAN MD

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 1477521607 NPI number — EDWARD H MKRDICHIAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MKRDICHIAN
Provider First Name:
EDWARD
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1477521607
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4501 N WINCHESTER AVE
Provider Second Line Business Mailing Address:
3RD FL
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-250-0500
Provider Business Mailing Address Fax Number:
773-250-0497

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4501 N WINCHESTER AVE
Provider Second Line Business Practice Location Address:
3RD FL
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-250-0500
Provider Business Practice Location Address Fax Number:
773-250-0497
Provider Enumeration Date:
03/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  036063585 , 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: 0360635851 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com