Provider Demographics
NPI:1336267855
Name:MDM ADVANCED ANCILLARY SERVICES, LLC
Entity Type:Organization
Organization Name:MDM ADVANCED ANCILLARY SERVICES, LLC
Other - Org Name:ADVANCED ANCILLARY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:KNIPPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-478-6434
Mailing Address - Street 1:DEPT 10116
Mailing Address - Street 2:PO BOX 87618
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-0618
Mailing Address - Country:US
Mailing Address - Phone:708-478-6417
Mailing Address - Fax:708-535-8087
Practice Address - Street 1:19065 HICKORY CREEK PL
Practice Address - Street 2:SUITE 240
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8507
Practice Address - Country:US
Practice Address - Phone:708-478-6417
Practice Address - Fax:708-535-8087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization