Provider Demographics
NPI:1982703856
Name:MGM MEDICAL ASSOCIATES, LTD. SC
Entity Type:Organization
Organization Name:MGM MEDICAL ASSOCIATES, LTD. SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MEERA
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:MADAPPALLIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-414-4460
Mailing Address - Street 1:8345 W MAYNARD RD
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-1058
Mailing Address - Country:US
Mailing Address - Phone:847-983-4215
Mailing Address - Fax:847-983-9215
Practice Address - Street 1:2425 W 22ND ST
Practice Address - Street 2:SUITE: 211
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1245
Practice Address - Country:US
Practice Address - Phone:630-368-3909
Practice Address - Fax:630-368-3958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104910207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========-60070-01Medicaid
IL=========-60070-01Medicaid
IL209858Medicare ID - Type UnspecifiedCOOK COUNTY
IL209857Medicare ID - Type UnspecifiedDUPAGE COUNTY