Provider Demographics
NPI:1922414358
Name:MEDINTEL PC
Entity Type:Organization
Organization Name:MEDINTEL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KVIRIKADZE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-750-9696
Mailing Address - Street 1:532 LOCKARD LN
Mailing Address - Street 2:
Mailing Address - City:HIGHWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60040-1223
Mailing Address - Country:US
Mailing Address - Phone:773-750-9696
Mailing Address - Fax:224-848-6296
Practice Address - Street 1:532 LOCKARD LN
Practice Address - Street 2:
Practice Address - City:HIGHWOOD
Practice Address - State:IL
Practice Address - Zip Code:60040-1223
Practice Address - Country:US
Practice Address - Phone:773-750-9696
Practice Address - Fax:224-848-6296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114198261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036114198Medicaid