Provider Demographics
NPI:1730473067
Name:MAKER SURGICAL, S.C.
Entity Type:Organization
Organization Name:MAKER SURGICAL, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:K
Authorized Official - Last Name:MAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:773-296-5346
Mailing Address - Street 1:1055 HILLCREST RD
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:IL
Mailing Address - Zip Code:60022-1215
Mailing Address - Country:US
Mailing Address - Phone:773-296-5346
Mailing Address - Fax:773-296-5570
Practice Address - Street 1:3000 N HALSTED ST
Practice Address - Street 2:SUITE 500
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5188
Practice Address - Country:US
Practice Address - Phone:773-296-5346
Practice Address - Fax:773-296-5570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036045277208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036045277Medicaid
IL222350OtherPTAN
IL222350OtherPTAN