Healthcare Provider Details

I. General information

NPI: 1659529162
Provider Name (Legal Business Name): MADAMBA MEDICAL ASSOCIATES SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 09/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1431 N WESTERN AVE SUITE 203
CHICAGO IL
60622-1797
US

IV. Provider business mailing address

5332 N KILDARE AVE
CHICAGO IL
60630-1759
US

V. Phone/Fax

Practice location:
  • Phone: 773-278-1222
  • Fax: 773-278-4598
Mailing address:
  • Phone: 773-463-3632
  • Fax: 773-278-4598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number336014028
License Number StateIL

VIII. Authorized Official

Name: EDUARDO N MADAMBA
Title or Position: PRESIDENT
Credential: MD
Phone: 773-463-3632