Provider Demographics
NPI:1437304631
Name:CAMBRIDGE MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:CAMBRIDGE MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:P
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-333-1980
Mailing Address - Street 1:900 S HIGHWAY DR STE 305
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2042
Mailing Address - Country:US
Mailing Address - Phone:800-333-1980
Mailing Address - Fax:636-326-9735
Practice Address - Street 1:1550 N MANNHEIM RD STE C
Practice Address - Street 2:
Practice Address - City:STONE PARK
Practice Address - State:IL
Practice Address - Zip Code:60165-1300
Practice Address - Country:US
Practice Address - Phone:800-333-1980
Practice Address - Fax:636-326-9735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-02
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty