Provider Demographics
NPI:1487898417
Name:MARANATHA FAMILY MEDICINE
Entity type:Organization
Organization Name:MARANATHA FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:LASKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-949-8474
Mailing Address - Street 1:550 N MIDLOTHIAN RD
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-1613
Mailing Address - Country:US
Mailing Address - Phone:847-949-8474
Mailing Address - Fax:847-949-4825
Practice Address - Street 1:550 N MIDLOTHIAN RD
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-1613
Practice Address - Country:US
Practice Address - Phone:847-949-8474
Practice Address - Fax:847-949-4825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036063544207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL86574Medicare PIN