Provider Demographics
NPI:1396789053
Name:MAYUGA MEDICAL PRACTICE
Entity type:Organization
Organization Name:MAYUGA MEDICAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUPERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYUGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-281-7660
Mailing Address - Street 1:18W 163 HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:IL
Mailing Address - Zip Code:60561
Mailing Address - Country:US
Mailing Address - Phone:847-676-0091
Mailing Address - Fax:847-676-2374
Practice Address - Street 1:2800 N SHERIDAN RD
Practice Address - Street 2:SUITE303
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6156
Practice Address - Country:US
Practice Address - Phone:773-281-7660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075687207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01605124OtherBLUE CROSS BLUE SHIELD IL
IL036075687Medicaid
IL200943Medicare ID - Type Unspecified