MEDICARE: ERIE FAMILY HEALTH CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)		IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	748480	OTHER	IL	MEDICARE PART B

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1616827	OTHER	IL	BLUE CROSS BLUE SHIELD PROVIDE NUMBER

General Provider Information

NPI Number	:	1043407547
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ERIE FAMILY HEALTH CENTER INC

Provider Business Mailing Address
First Line	:	1701 W SUPERIOR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-5646
Country	:	US
Telephone Number	:	312-666-3494
Fax Number	:	312-666-0610

Provider Business Practice Location Address
First Line	:	1504 S ALBANY
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-2209
Country	:	US
Telephone Number	:	312-666-3494
Fax Number	:	312-666-0610

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	LEE FRANCIS
Credential	:
Telephone Number	:	312-432-7394

Provider Enumeration Date	:	09/28/2007
Last Update Date	:	11/02/2020

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