Healthcare Provider Details

I. General information

NPI: 1285854067
Provider Name (Legal Business Name): GREAT HEIGHTS FAMILY MEDICINE LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1473 RING RD
CALUMET CITY IL
60409-5459
US

IV. Provider business mailing address

1473 RING RD
CALUMET CITY IL
60409-5459
US

V. Phone/Fax

Practice location:
  • Phone: 312-952-9378
  • Fax: 708-862-8105
Mailing address:
  • Phone: 312-952-9378
  • Fax: 708-862-8105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number65528584
License Number StateIL

VIII. Authorized Official

Name: DR. ADEYEMI OLUDARE FATOKI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 708-862-8156