Provider Demographics
NPI:1225101926
Name:NEPOMUCENO MEDICAL ASSOCIATES,SC.
Entity Type:Organization
Organization Name:NEPOMUCENO MEDICAL ASSOCIATES,SC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP/TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDILBERTO
Authorized Official - Middle Name:ELAZEGUI
Authorized Official - Last Name:NEPOMUCENO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:708-799-6363
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60412-0370
Mailing Address - Country:US
Mailing Address - Phone:708-799-6363
Mailing Address - Fax:708-799-6399
Practice Address - Street 1:18811 DIXIE HWY
Practice Address - Street 2:SUITE 200
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-3919
Practice Address - Country:US
Practice Address - Phone:708-799-6363
Practice Address - Fax:708-799-6399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069957174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL566680Medicare ID - Type UnspecifiedMEDICARE GROUP #