Provider Demographics
NPI:1639601644
Name:MEDAIROS, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:MEDAIROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 S LAFLIN ST
Mailing Address - Street 2:APARTMENT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4619
Mailing Address - Country:US
Mailing Address - Phone:414-805-4000
Mailing Address - Fax:
Practice Address - Street 1:1013 S LAFLIN ST
Practice Address - Street 2:APARTMENT 2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-4619
Practice Address - Country:US
Practice Address - Phone:414-805-0788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-29
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program