=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487262192
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDREAT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2020
-----------------------------------------------------
Last Update Date | 09/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1436 DEERFIELD RD
-----------------------------------------------------
City | DEERFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-2758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-731-0331
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1436 DEERFIELD RD
-----------------------------------------------------
City | DEERFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-2758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-300-8881
-----------------------------------------------------
Fax | 708-438-7709
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KOJIRO MATSUMOTO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 708-300-8881
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------