1063566487 NPI number — DELIS FAMILY MEDICAL, S.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063566487 NPI number — DELIS FAMILY MEDICAL, S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DELIS FAMILY MEDICAL, 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:
1063566487
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4116 CRESTWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60062-7545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-205-1464
Provider Business Mailing Address Fax Number:
847-205-1464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2740 W FOSTER AVE
Provider Second Line Business Practice Location Address:
STE. 316
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60625-3500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-561-8481
Provider Business Practice Location Address Fax Number:
773-561-8495
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DELIS
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
GEORGE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
312-593-0713

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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