MEDICARE: SOUTHTOWN MEDICAL CENTER, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	208D00000X	General Practice Physician	IL
2	208000000X	Pediatrics Physician	IL
3	207Q00000X	Family Medicine Physician	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	1174528061	OTHER	IL	MEDICARE NPI
4	1356346241	OTHER	IL	MEDICARE NPI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	1634276	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1629022058
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHTOWN MEDICAL CENTER, LLC

Provider Business Mailing Address
First Line	:	6342 S PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-4706
Country	:	US
Telephone Number	:	773-284-8601
Fax Number	:

Provider Business Practice Location Address
First Line	:	6342 S PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60629-4706
Country	:	US
Telephone Number	:	773-284-8601
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	VENKATA A VALLURY
Credential	:	MD
Telephone Number	:	773-284-8601

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	05/02/2008

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Directions to “SOUTHTOWN MEDICAL CENTER, LLC ” Practice Location

Language	Start Address	Practice Location

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