Provider Demographics
NPI:1275608358
Name:MAINE RIDGE MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:MAINE RIDGE MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-767-3822
Mailing Address - Street 1:9301 GOLF RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-1667
Mailing Address - Country:US
Mailing Address - Phone:847-296-8151
Mailing Address - Fax:847-296-3915
Practice Address - Street 1:9301 GOLF RD
Practice Address - Street 2:SUITE 302
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1667
Practice Address - Country:US
Practice Address - Phone:847-296-8151
Practice Address - Fax:847-296-3915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX IDENTIFICATION
IL605260Medicare ID - Type UnspecifiedMEDICARE GP PROVIDER NUMB