Provider Demographics
NPI:1134622053
Name:MAINSTAY CLINICS, INC.
Entity type:Organization
Organization Name:MAINSTAY CLINICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:JAROSZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-717-0447
Mailing Address - Street 1:17942 W POND RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-4534
Mailing Address - Country:US
Mailing Address - Phone:224-717-0447
Mailing Address - Fax:
Practice Address - Street 1:109 N SEYMOUR AVE
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-2318
Practice Address - Country:US
Practice Address - Phone:224-864-2124
Practice Address - Fax:224-864-2178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-16
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009332363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363L00000XOtherTAXONOMY
IL2011015746OtherANCC
IL338829946001Medicaid