Healthcare Provider Details

I. General information

NPI: 1275729287
Provider Name (Legal Business Name): H DEMITRI MEDICAL SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2007
Last Update Date: 01/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 N ADDISON RD
ADDISON IL
60101-3875
US

IV. Provider business mailing address

3960 N HARLEM AVE
CHICAGO IL
60634-2219
US

V. Phone/Fax

Practice location:
  • Phone: 630-530-4144
  • Fax: 630-530-7404
Mailing address:
  • Phone: 773-658-2300
  • Fax: 773-658-2305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL

VII. Legacy identifiers

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

# 1
Identifier01634343
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBLUE CROSS BLUE SHIELD PI

VIII. Authorized Official

Name: DR. HARALAMBOS HATZIDIMITRIADIS
Title or Position: PRESIDENT
Credential: MD
Phone: 773-658-2300