Provider Demographics
NPI:1275729303
Name:MACENTEE KNOX & VARGAS MDS
Entity Type:Organization
Organization Name:MACENTEE KNOX & VARGAS MDS
Other - Org Name:SOUTHCARE FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:F
Authorized Official - Last Name:MACENTEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-779-9300
Mailing Address - Street 1:10627 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-3827
Mailing Address - Country:US
Mailing Address - Phone:773-779-9300
Mailing Address - Fax:773-779-5768
Practice Address - Street 1:10627 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-3827
Practice Address - Country:US
Practice Address - Phone:773-779-9300
Practice Address - Fax:773-779-5768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072512305R00000X
IL036047977305R00000X
IL036063080305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL77296Medicare PIN
IL750290Medicare PIN
ILP09567Medicare PIN
ILP09566Medicare PIN