Provider Demographics
NPI:1740359876
Name:MOKENA FAMILY PHYSICIANS LLC
Entity type:Organization
Organization Name:MOKENA FAMILY PHYSICIANS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-479-4681
Mailing Address - Street 1:11243 W LA PORTE RD
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-1374
Mailing Address - Country:US
Mailing Address - Phone:708-479-4681
Mailing Address - Fax:708-479-8516
Practice Address - Street 1:11243 W LA PORTE RD
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-1374
Practice Address - Country:US
Practice Address - Phone:708-479-4681
Practice Address - Fax:708-479-8516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085722261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085722Medicaid
IL036077425Medicaid
IL036077425Medicaid
ILF31981Medicare UPIN
ILK01488Medicare ID - Type Unspecified
ILK01489Medicare ID - Type Unspecified