Healthcare Provider Details

I. General information

NPI: 1861964959
Provider Name (Legal Business Name): MIDWAY MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2018
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 W 103RD ST
CHICAGO IL
60628-2619
US

IV. Provider business mailing address

2 W 103RD ST
CHICAGO IL
60628-2619
US

V. Phone/Fax

Practice location:
  • Phone: 773-597-7698
  • Fax:
Mailing address:
  • Phone: 773-597-7698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARVIN COK
Title or Position: STAFF
Credential:
Phone: 773-597-7698