Basic Information
| Provider Information | |||||||||
| NPI: | 1477709699 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENEZES | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 S DESPLAINES ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606615500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126542700 | ||||||||
| FaxNumber: | 3126549930 | ||||||||
| Practice Location | |||||||||
| Address1: | 1550 NORTHWEST HIGHWAY | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600681411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472945160 | ||||||||
| FaxNumber: | 8472949962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2008 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 125-051654 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | 036121790 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 036121790 | 05 | IL | MEDICAID |