=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659529162
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MADAMBA MEDICAL ASSOCIATES SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2008
-----------------------------------------------------
Last Update Date | 09/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1431 N WESTERN AVE SUITE 203
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-1797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-278-1222
-----------------------------------------------------
Fax | 773-278-4598
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5332 N KILDARE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60630-1759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-463-3632
-----------------------------------------------------
Fax | 773-278-4598
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | EDUARDO N MADAMBA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 773-463-3632
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 336014028
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------