Healthcare Provider Details

I. General information

NPI: 1629128319
Provider Name (Legal Business Name): PROGRESSIVE MEDICAL CENTER SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 04/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 W LAKE STREET
ADDISON IL
60101
US

IV. Provider business mailing address

1841 W ARMY TRAIL RD
ADDISON IL
60101-1901
US

V. Phone/Fax

Practice location:
  • Phone: 630-458-1905
  • Fax: 630-458-1908
Mailing address:
  • Phone: 630-238-9235
  • Fax: 630-620-0581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036103673
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036107571
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036078267
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036087152
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier036109448
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer
# 2
Identifier036078267
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer
# 3
Identifier036103673
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer
# 4
Identifier036087152
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer
# 5
Identifier2205538
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBCBS OF ILLINOIS

VIII. Authorized Official

Name: GABRIELA HENRIQUEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 630-238-9235