Basic Information
| Provider Information | |||||||||
| NPI: | 1396367108 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALDONADO | ||||||||
| FirstName: | GENESSIS | ||||||||
| MiddleName: | CRISTINA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3249 S. OAK PARK AVE | ||||||||
| Address2: | |||||||||
| City: | BERWYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087833401 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3722 SOUTH HARLEM AVE. | ||||||||
| Address2: | SUITE LL34 MACNEAL CENTER FOR INTERNAL MEDICINE | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087836566 | ||||||||
| FaxNumber: | 7087836567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2020 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/17/2022 | ||||||||
| NPIReactivationDate: | 02/03/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 125076942 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.