Provider Demographics
NPI:1144795279
Name:MIINEDOCTOR, INC.
Entity Type:Organization
Organization Name:MIINEDOCTOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-972-7636
Mailing Address - Street 1:13755 CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60418-1824
Mailing Address - Country:US
Mailing Address - Phone:708-972-7636
Mailing Address - Fax:
Practice Address - Street 1:13755 CICERO AVE
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60418-1824
Practice Address - Country:US
Practice Address - Phone:708-972-7642
Practice Address - Fax:708-925-9179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-04
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty