Provider Demographics
NPI:1184801706
Name:NAPERBROOK MEDICAL CENTER
Entity type:Organization
Organization Name:NAPERBROOK MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MEHER
Authorized Official - Middle Name:BALA
Authorized Official - Last Name:MEDAVARAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-378-1234
Mailing Address - Street 1:686 W BOUGHTON RD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1520
Mailing Address - Country:US
Mailing Address - Phone:630-378-1234
Mailing Address - Fax:630-378-1155
Practice Address - Street 1:686 W BOUGHTON RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1520
Practice Address - Country:US
Practice Address - Phone:630-378-1234
Practice Address - Fax:630-378-1155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-25
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042-007177261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09921620OtherBLUECROSS BLUESHIELD
ILG41052Medicare UPIN
IL334770Medicare PIN