Healthcare Provider Details

I. General information

NPI: 1518622802
Provider Name (Legal Business Name): MPAC TI OF IN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2021
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N LA SALLE ST STE 1550
CHICAGO IL
60601-1034
US

IV. Provider business mailing address

8520 ALLISON POINTE BLVD STE 223 PMB 41391
INDIANAPOLIS IN
46250-4299
US

V. Phone/Fax

Practice location:
  • Phone: 888-705-8722
  • Fax:
Mailing address:
  • Phone: 888-705-8722
  • Fax: 888-705-8722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: TIMOTHY MARTINEZ
Title or Position: CEO
Credential:
Phone: 888-660-4425