Provider Demographics
NPI:1881640902
Name:KOMPERDA, MARY (APN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KOMPERDA
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 W NORTH AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1634
Mailing Address - Country:US
Mailing Address - Phone:708-450-5094
Mailing Address - Fax:708-344-0508
Practice Address - Street 1:675 W NORTH AVE
Practice Address - Street 2:STE-210
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1634
Practice Address - Country:US
Practice Address - Phone:708-450-5094
Practice Address - Fax:708-344-0508
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-004003363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209712OtherMEDICARE GROUP NUMBER
IL31602469OtherBLUE CROSS BLUE SHIELD GROUP PROVIDER NUMBER
ILP00236752OtherRAILROAD MEDICARE INDIVIDUAL PROVIDER ID
IL1164530713OtherCONSULTANTS IN CARDIOVASCULAR MEDICINE, S.C. GROUP NPI NUMBER
IL961280OtherMEDICARE GROUP NUMBER
ILCC1592OtherRAILROAD MEDICARE GROUP PTAN NUMBER
ILK18549OtherMEDICARE INDIVIDUAL PTAN NUMBER
IL209712OtherMEDICARE GROUP NUMBER