Provider Demographics
NPI:1689671398
Name:WHOLLY ROMAN EMPIRE INC
Entity Type:Organization
Organization Name:WHOLLY ROMAN EMPIRE INC
Other - Org Name:MERRICK HOPKINS PROSTHETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROMAN
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:773-586-2222
Mailing Address - Street 1:5956 DOVER RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61109-1733
Mailing Address - Country:US
Mailing Address - Phone:773-586-2222
Mailing Address - Fax:773-586-5566
Practice Address - Street 1:6655 W ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2419
Practice Address - Country:US
Practice Address - Phone:773-586-2222
Practice Address - Fax:773-586-5566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL335E00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid