Provider Demographics
NPI:1659529162
Name:MADAMBA MEDICAL ASSOCIATES SC
Entity Type:Organization
Organization Name:MADAMBA MEDICAL ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:N
Authorized Official - Last Name:MADAMBA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-463-3632
Mailing Address - Street 1:5332 N KILDARE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-1759
Mailing Address - Country:US
Mailing Address - Phone:773-463-3632
Mailing Address - Fax:773-278-4598
Practice Address - Street 1:1431 N WESTERN AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1797
Practice Address - Country:US
Practice Address - Phone:773-278-1222
Practice Address - Fax:773-278-4598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336014028207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0021604377OtherBLUE CROSS BLUE SHIELD OF ILLINOIS
IL036047978Medicaid
IL0021604377OtherBLUE CROSS BLUE SHIELD OF ILLINOIS