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 PROVIDER NUMBER

General Provider Information

NPI Number	:	1952598468
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ERIE FAMILY HEALTH CENTER, INC

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

Provider Business Practice Location Address
First Line	:	4759 N KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-4420
Country	:	US
Telephone Number	:	312-666-3494
Fax Number	:

Authorized Official
Title or Position	:	BILLING DEPARTMENT SUPERVISOR
Name	:	MISS GABRIELA NORENA
Credential	:
Telephone Number	:	312-432-7444

Provider Enumeration Date	:	09/28/2007
Last Update Date	:	06/02/2008

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