Provider Demographics
NPI:1124776661
Name:MED MK LLC
Entity type:Organization
Organization Name:MED MK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAYYURATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KANAGGAPPAH MAHESWARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-483-3171
Mailing Address - Street 1:7120 N SHERIDAN RD APT 304
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-2906
Mailing Address - Country:US
Mailing Address - Phone:312-483-3171
Mailing Address - Fax:
Practice Address - Street 1:1785 W HOWARD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-1626
Practice Address - Country:US
Practice Address - Phone:312-483-3171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center