Provider Demographics
NPI:1124112461
Name:MIDWEST MEDICORP, SC
Entity type:Organization
Organization Name:MIDWEST MEDICORP, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:RAFIE-SAFAIE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:773-229-9600
Mailing Address - Street 1:6524 W ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2400
Mailing Address - Country:US
Mailing Address - Phone:773-229-9600
Mailing Address - Fax:773-229-9611
Practice Address - Street 1:6524 W ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2400
Practice Address - Country:US
Practice Address - Phone:773-229-9600
Practice Address - Fax:773-229-9611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
IL016004709213ES0103X
IL036096853208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty