MEDICARE: MED MK LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1124776661
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MED MK LLC

Provider Business Mailing Address
First Line	:	7120 N SHERIDAN RD APT 304
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-2906
Country	:	US
Telephone Number	:	312-483-3171
Fax Number	:

Provider Business Practice Location Address
First Line	:	1785 W HOWARD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-1626
Country	:	US
Telephone Number	:	312-483-3171
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MAYYURATHAN KANAGGAPPAH MAHESWARA
Credential	:
Telephone Number	:	312-483-3171

Provider Enumeration Date	:	03/14/2022
Last Update Date	:	03/14/2022

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Directions to “MED MK LLC ” Practice Location

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