Provider Demographics
NPI:1245753755
Name:MAXICARE VISITING PHYSICIAN, INC
Entity Type:Organization
Organization Name:MAXICARE VISITING PHYSICIAN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-961-7580
Mailing Address - Street 1:3300 W PETERSON AVE STE H
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3585
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3300 W PETERSON AVE
Practice Address - Street 2:SUITE H
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659
Practice Address - Country:US
Practice Address - Phone:773-961-7580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-18
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service