1508294091 NPI number — SOUTH SHORE SCHOOL OF LEADERSHIP HEALTH CENTER

Table of content: (NPI 1508294091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508294091 NPI number — SOUTH SHORE SCHOOL OF LEADERSHIP HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH SHORE SCHOOL OF LEADERSHIP HEALTH CENTER
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:
FRIEDELL PRIMARY CARE
Provider Other Organization Name Type Code:
3
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:
1508294091
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2850 S WABASH AVE
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60616-2955
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-808-0621
Provider Business Mailing Address Fax Number:
312-808-0655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7627 S CONSTANCE 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:
60649-4009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-535-7406
Provider Business Practice Location Address Fax Number:
312-808-0655
Provider Enumeration Date:
10/22/2013

Additional Information

Authorized Official

Authorized Official Last Name:
FRIEDELL
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
312-808-0621

Provider Taxonomy Codes

  • Taxonomy code: 261QS1000X , with the licence number:  042617358 , 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)





Copyright © 2007-2024 www.npivalidator.com