Provider Demographics
NPI:1669798526
Name:CORNELL ABRAXAS MIDWEST
Entity type:Organization
Organization Name:CORNELL ABRAXAS MIDWEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:INEZ
Authorized Official - Middle Name:C
Authorized Official - Last Name:FERRANTE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:419-747-0819
Mailing Address - Street 1:2221 64TH ST
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-2180
Mailing Address - Country:US
Mailing Address - Phone:630-968-6477
Mailing Address - Fax:
Practice Address - Street 1:2221 64TH ST
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-2180
Practice Address - Country:US
Practice Address - Phone:630-968-6477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORNELL ABRAXAS GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center