Healthcare Provider Details

I. General information

NPI: 1114909363
Provider Name (Legal Business Name): ANNIE JOHN, M.D.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 09/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3434 W PETERSON AVE 1A
CHICAGO IL
60659-3319
US

IV. Provider business mailing address

P. O. BOX 2248
CAROL STREAM IL
60132-2248
US

V. Phone/Fax

Practice location:
  • Phone: 773-583-5803
  • Fax:
Mailing address:
  • Phone: 847-676-0091
  • Fax: 847-676-2374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number209-003580
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number036-068169
License Number StateIL

VIII. Authorized Official

Name: DR. ANNIE JOHN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 773-989-3977