1255560470 NPI number — GREATER CHICAGO MEDICAL GROUP, S.C.

Table of content: (NPI 1255560470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255560470 NPI number — GREATER CHICAGO MEDICAL GROUP, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREATER CHICAGO MEDICAL GROUP, S.C.
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:
Provider Other Organization Name Type Code:
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:
1255560470
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 68726
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCHAUMBURG
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60168-0726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-987-3795
Provider Business Mailing Address Fax Number:
847-352-0423

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8700 S DANTE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60619-7118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-221-3900
Provider Business Practice Location Address Fax Number:
847-352-0423
Provider Enumeration Date:
07/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SALDANHA
Authorized Official First Name:
RITA
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
708-987-3795

Provider Taxonomy Codes

  • Taxonomy code: 103TP2701X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 64612247 . This is a "CORPORATE FILE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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