Provider Demographics
NPI:1083896914
Name:MARIA MEDICAL LLC
Entity Type:Organization
Organization Name:MARIA MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ANEMARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUTAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-226-9950
Mailing Address - Street 1:1307 BRANDYWINE DR
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-4331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 E BOUGHTON RD
Practice Address - Street 2:SUITE 140
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2100
Practice Address - Country:US
Practice Address - Phone:630-226-9950
Practice Address - Fax:630-378-9952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104904207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH75098Medicare UPIN
IL210923Medicare PIN