Healthcare Provider Details

I. General information

NPI: 1053816835
Provider Name (Legal Business Name): MEDOVATE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 10/27/2022
Certification Date: 10/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 BUSCH PKWY STE 145
BUFFALO GROVE IL
60089-4541
US

IV. Provider business mailing address

1237 COUNTRY LN
DEERFIELD IL
60015-4722
US

V. Phone/Fax

Practice location:
  • Phone: 847-499-5500
  • Fax:
Mailing address:
  • Phone: 847-530-1215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: DAVID MANN
Title or Position: OWNER
Credential: MD
Phone: 847-530-1215