1821159625 NPI number — 31ST STD CLINIC

Table of content: (NPI 1821159625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821159625 NPI number — 31ST STD CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
31ST STD CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
31ST STREET SEXUALLY TRANSMITTED DISEASES
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821159625
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 S STATE STREET
Provider Second Line Business Mailing Address:
REVENUE #200 CHICAGO DEPARTMENT OF PUBLIC HEALTH
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-747-9792
Provider Business Mailing Address Fax Number:
312-747-9447

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
530 E 31ST ST
Provider Second Line Business Practice Location Address:
STD 31ST STREET CLINIC
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60616-4008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-747-9792
Provider Business Practice Location Address Fax Number:
312-747-9447
Provider Enumeration Date:
12/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
SARAI
Authorized Official Middle Name:
M
Authorized Official Title or Position:
DIRECTOR OF REVENUE
Authorized Official Telephone Number:
312-747-9792

Provider Taxonomy Codes

  • Taxonomy code: 2083P0901X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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