Provider Demographics
NPI:1396768727
Name:MAVENA DERMA CENTERS, INC.
Entity type:Organization
Organization Name:MAVENA DERMA CENTERS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGINNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-483-9621
Mailing Address - Street 1:500 N. MICHIGAN AVENUE
Mailing Address - Street 2:300
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3777
Mailing Address - Country:US
Mailing Address - Phone:847-298-9400
Mailing Address - Fax:847-298-7660
Practice Address - Street 1:1100 W CENTRAL RD
Practice Address - Street 2:306
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2402
Practice Address - Country:US
Practice Address - Phone:847-483-9621
Practice Address - Fax:847-483-9625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01636236OtherBCBS
IL214157Medicare PIN