Basic Information
| Provider Information | |||||||||
| NPI: | 1366492324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TWADDLE | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, FACP, FAAHPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25400 N SAINT MARYS RD | ||||||||
| Address2: | |||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600489460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475561697 | ||||||||
| FaxNumber: | 8475561505 | ||||||||
| Practice Location | |||||||||
| Address1: | 2050 CLAIRE COURT | ||||||||
| Address2: | |||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600257635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474677423 | ||||||||
| FaxNumber: | 8475561505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 07/23/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036-074835 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0002X | 036-074835 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036-074835 | 05 | IL | MEDICAID |