Healthcare Provider Details

I. General information

NPI: 1093530362
Provider Name (Legal Business Name): MADISON CAROL MEDINA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15300 WEST AVE STE 100
ORLAND PARK IL
60462-4600
US

IV. Provider business mailing address

15300 WEST AVE STE 100
ORLAND PARK IL
60462-4600
US

V. Phone/Fax

Practice location:
  • Phone: 708-923-4400
  • Fax: 708-590-6605
Mailing address:
  • Phone: 708-923-4400
  • Fax: 708-590-6605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.011066
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: