Basic Information
Provider Information | |||||||||
NPI: | 1588607923 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MONROE MEDICAL ASSOCIATES, SC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 801 MACARTHUR BLVD | ||||||||
Address2: | SUITE 401 | ||||||||
City: | MUNSTER | ||||||||
State: | IN | ||||||||
PostalCode: | 463212915 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2198362860 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6701 159TH ST | ||||||||
Address2: | SUITE 1 | ||||||||
City: | TINLEY PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 604771758 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7084442226 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2006 | ||||||||
LastUpdateDate: | 10/07/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KOZLOFF | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: | F | ||||||||
AuthorizedOfficialTitleorPosition: | CEO / SENIOR PARTNER | ||||||||
AuthorizedOfficialTelephone: | 7083394800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
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 | CA8459 | 01 | IL | RR MCARE GRP PIN | OTHER | CE1551 | 01 | IN | RR MCARE GRP PIN | OTHER | 105630 | 01 | IN | ANTHEM B S GRP PROV # | OTHER | 042003867 | 01 | IL | IL REG MED CORP # | OTHER | 100394430 | 05 | IN |   | MEDICAID | 1615180 | 01 | IL | B C B S GROUP PROV # | OTHER |