Healthcare Provider Details

I. General information

NPI: 1487883054
Provider Name (Legal Business Name): MELAMPUS, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2009
Last Update Date: 07/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277 SYLVAN RD
GLENCOE IL
60022-1225
US

IV. Provider business mailing address

277 SYLVAN RD
GLENCOE IL
60022-1225
US

V. Phone/Fax

Practice location:
  • Phone: 847-835-0277
  • Fax: 847-835-0277
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number036035290
License Number StateIL

VIII. Authorized Official

Name: DR. MARVIN FREEDMAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 847-835-0277