Provider Demographics
NPI:1831231166
Name:MIDLAKE MEDICAL CORPORATION
Entity type:Organization
Organization Name:MIDLAKE MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REUBEN
Authorized Official - Middle Name:TERRANCE
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-808-1600
Mailing Address - Street 1:2930 SOUTH MICHIGAN AVENUE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3484
Mailing Address - Country:US
Mailing Address - Phone:312-808-1600
Mailing Address - Fax:312-808-0985
Practice Address - Street 1:2930 SOUTH MICHIGAN AVENUE
Practice Address - Street 2:SUITE 101
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3484
Practice Address - Country:US
Practice Address - Phone:312-808-1600
Practice Address - Fax:312-808-0985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
426910Medicare UPIN