MEDICARE: FULLERTON OCCUPATIONAL MEDICINE & IMMEDIATE CARE SC

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	261QP2000X	Physical Therapy Clinic/Center	364061160	IL
2	261QU0200X	Urgent Care Clinic/Center	364061160	IL
3	261QX0100X	Occupational Medicine Clinic/Center	364061160	IL

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	01635426	OTHER	IL	OTHER

General Provider Information

NPI Number	:	1740304757
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULLERTON OCCUPATIONAL MEDICINE & IMMEDIATE CARE SC

Provider Business Mailing Address
First Line	:	3409 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2415
Country	:	US
Telephone Number	:	773-486-5001
Fax Number	:

Provider Business Practice Location Address
First Line	:	3409 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2415
Country	:	US
Telephone Number	:	773-486-5001
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RENLIN XIA
Credential	:	MD
Telephone Number	:	773-486-5001

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	04/13/2010

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