MEDICARE: MIDWAY MEDICAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QM2800X	Methadone Clinic
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center
3	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1861964959
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWAY MEDICAL

Provider Business Mailing Address
First Line	:	2 W 103RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60628-2619
Country	:	US
Telephone Number	:	773-597-7698
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 W 103RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60628-2619
Country	:	US
Telephone Number	:	773-597-7698
Fax Number	:

Authorized Official
Title or Position	:	STAFF
Name	:	MARVIN COK
Credential	:
Telephone Number	:	773-597-7698

Provider Enumeration Date	:	12/30/2018
Last Update Date	:	07/22/2021

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Directions to “MIDWAY MEDICAL ” Practice Location

Language	Start Address	Practice Location

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