Provider Demographics
NPI:1073805552
Name:CHICAGO MEDICAL ALLIANCE LLC
Entity Type:Organization
Organization Name:CHICAGO MEDICAL ALLIANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:VITALI
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-366-2159
Mailing Address - Street 1:2629 W CHICAGO AVE # IF
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-8182
Mailing Address - Country:US
Mailing Address - Phone:773-366-2159
Mailing Address - Fax:773-862-6300
Practice Address - Street 1:2219 W CHICAGO AVE APT 1F
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-4795
Practice Address - Country:US
Practice Address - Phone:773-366-2159
Practice Address - Fax:773-862-6300
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHICAGO MEDICAL ALLIANCE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2092906332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies