Healthcare Provider Details

I. General information

NPI: 1336195882
Provider Name (Legal Business Name): THIDA MAW MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 RANDALL RD
CARPENTERSVILLE IL
60110-3355
US

IV. Provider business mailing address

2201 RANDALL RD
CARPENTERSVILLE IL
60110-3355
US

V. Phone/Fax

Practice location:
  • Phone: 847-428-1179
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: THIDA MAW
Title or Position: OWNER / PHYSICIAN
Credential: MD
Phone: 847-428-1179