Provider Demographics
NPI:1124586151
Name:VITAL MEDICAL NETWORK
Entity type:Organization
Organization Name:VITAL MEDICAL NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-560-6151
Mailing Address - Street 1:PO BOX 734116
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-4116
Mailing Address - Country:US
Mailing Address - Phone:312-462-4081
Mailing Address - Fax:312-276-4064
Practice Address - Street 1:17 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-4844
Practice Address - Country:US
Practice Address - Phone:312-462-4081
Practice Address - Fax:312-276-4064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-08
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203.002039OtherDME LICENSE