Healthcare Provider Details

I. General information

NPI: 1124586151
Provider Name (Legal Business Name): VITAL MEDICAL NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2019
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 W GRAND AVE
CHICAGO IL
60654-4844
US

IV. Provider business mailing address

PO BOX 734116
CHICAGO IL
60673-4116
US

V. Phone/Fax

Practice location:
  • Phone: 312-462-4081
  • Fax: 312-276-4064
Mailing address:
  • Phone: 312-462-4081
  • Fax: 312-276-4064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. ED BAUER
Title or Position: PARTNER
Credential:
Phone: 312-560-6151