Provider Demographics
NPI:1386860864
Name:ST AGNES MEDICAL EQUIPMENT CO INC
Entity Type:Organization
Organization Name:ST AGNES MEDICAL EQUIPMENT CO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:312-787-9400
Mailing Address - Street 1:1541 N WELLS ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-1307
Mailing Address - Country:US
Mailing Address - Phone:312-787-9400
Mailing Address - Fax:312-787-9434
Practice Address - Street 1:2540 S WABASH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2309
Practice Address - Country:US
Practice Address - Phone:312-674-9494
Practice Address - Fax:312-674-9595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0328570001Medicare NSC