Provider Demographics
NPI:1568742542
Name:MD2 CHICAGO
Entity Type:Organization
Organization Name:MD2 CHICAGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:HENNESSY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-780-2301
Mailing Address - Street 1:676 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 3120
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2883
Mailing Address - Country:US
Mailing Address - Phone:312-780-2301
Mailing Address - Fax:312-780-2304
Practice Address - Street 1:676 N MICHIGAN AVE
Practice Address - Street 2:SUITE 3120
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2883
Practice Address - Country:US
Practice Address - Phone:312-780-2301
Practice Address - Fax:312-780-2304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082176302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036082176Medicaid
ILE83651Medicare UPIN