Provider Demographics
NPI:1093771263
Name:CORDIAL MEDICAL CENTER, S.C.
Entity Type:Organization
Organization Name:CORDIAL MEDICAL CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIKHAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:KHODARKOVSKIY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:224-392-3643
Mailing Address - Street 1:333 E IL ROUTE 83 STE 105
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-4278
Mailing Address - Country:US
Mailing Address - Phone:847-970-9922
Mailing Address - Fax:847-970-9955
Practice Address - Street 1:333 E IL ROUTE 83 STE 105
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-4278
Practice Address - Country:US
Practice Address - Phone:847-970-9922
Practice Address - Fax:847-970-9955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2023-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-107538207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL042-618285OtherCORPORATION LICENSE NO.
IL036-107538OtherPHYSICIAN LICENSE NO.