Provider Demographics
NPI:1538298500
Name:ENDALE MEKONEN MD PC
Entity Type:Organization
Organization Name:ENDALE MEKONEN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ENDALE
Authorized Official - Middle Name:
Authorized Official - Last Name:MEKONEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-479-6522
Mailing Address - Street 1:4425 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-2627
Mailing Address - Country:US
Mailing Address - Phone:708-479-6522
Mailing Address - Fax:708-479-6597
Practice Address - Street 1:4425 MADISON ST
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-2627
Practice Address - Country:US
Practice Address - Phone:708-479-6522
Practice Address - Fax:708-479-6597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085841207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085841Medicaid
IL392650Medicare ID - Type Unspecified
IL036085841Medicaid