MEDICARE: ELMWOOD PARK IMMEDIATE HEALTH CARE CENTER, LLC

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	207R00000X	Internal Medicine Physician	036112029	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01634215	OTHER	IL	BCBS GROUP NUMBER

General Provider Information

NPI Number	:	1356396758
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELMWOOD PARK IMMEDIATE HEALTH CARE CENTER, LLC

Provider Business Mailing Address
First Line	:	2333 N. HARLEM AVE.
Second Line	:	SUITE 100
City	:	CHICAGO
State	:	IL
Zip	:	60707-2718
Country	:	US
Telephone Number	:	773-637-2333
Fax Number	:	773-637-4229

Provider Business Practice Location Address
First Line	:	2333 N. HARLEM AVE
Second Line	:	SUITE 100
City	:	CHICAGO
State	:	IL
Zip	:	60707-2718
Country	:	US
Telephone Number	:	773-637-2333
Fax Number	:	773-637-4229

Authorized Official
Title or Position	:	COO
Name	:	MS. JOANNA BRZOSTOWSKA
Credential	:
Telephone Number	:	773-637-1700

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	10/17/2014

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