Healthcare Provider Details

I. General information

NPI: 1144795279
Provider Name (Legal Business Name): MIINEDOCTOR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13755 CICERO AVE
CRESTWOOD IL
60418-1824
US

IV. Provider business mailing address

13755 CICERO AVE
CRESTWOOD IL
60418-1824
US

V. Phone/Fax

Practice location:
  • Phone: 708-972-7642
  • Fax: 708-925-9179
Mailing address:
  • Phone: 708-972-7636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY ROCK
Title or Position: DIRECTOR OF CLINICAL OPERATIONS
Credential:
Phone: 708-972-7636