Basic Information
| Provider Information | |||||||||
| NPI: | 1447291547 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONROE MEDICAL ASSOCIATES, SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 MACARTHUR BLVD | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463212915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198362860 | ||||||||
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| Practice Location | |||||||||
| Address1: | 71 W 156TH ST | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | HARVEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604264260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083394800 | ||||||||
| FaxNumber: | 7083394814 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 10/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | KOZLOFF | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO / SENIOR PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7083394800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 042003867 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 105630 | 01 | IN | ANTHEM B S GRP PROV # | OTHER | 042003867 | 01 | IL | IL REG MED CORP # | OTHER | 1615180 | 01 | IL | B C B S GROUP PROV # | OTHER | 100394430 | 05 | IN | MEDICAID |