Provider Demographics
NPI:1184939571
Name:STEPHEN A. MADRY, MD SC
Entity type:Organization
Organization Name:STEPHEN A. MADRY, MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MADRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-382-9902
Mailing Address - Street 1:810 BIESTERFIELD RD # 308
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VLG
Mailing Address - State:IL
Mailing Address - Zip Code:60007-7312
Mailing Address - Country:US
Mailing Address - Phone:847-382-9902
Mailing Address - Fax:847-640-6831
Practice Address - Street 1:810 BIESTERFIELD RD # 308
Practice Address - Street 2:
Practice Address - City:ELK GROVE VLG
Practice Address - State:IL
Practice Address - Zip Code:60007-7312
Practice Address - Country:US
Practice Address - Phone:847-382-9902
Practice Address - Fax:847-640-6831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL564160Medicare PIN