Provider Demographics
NPI:1780614503
Name:BIRT, MAURICE W (MD)
Entity type:Individual
Prefix:
First Name:MAURICE
Middle Name:W
Last Name:BIRT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 WINFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-260-0600
Mailing Address - Fax:630-260-1370
Practice Address - Street 1:25 WINFIELD ROAD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1295
Practice Address - Country:US
Practice Address - Phone:630-260-0600
Practice Address - Fax:630-260-1370
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078879207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3631498336019001OtherCDPG HFS PAYEE ID
IL036078879Medicaid
IL363149833OtherTAX IDENTIFICATION NUMBER
IL0222075OtherBLUE CROSS NUMBER
IL548190Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
IL080116892Medicare PIN
IL036078879Medicaid