Healthcare Provider Details

I. General information

NPI: 1033575048
Provider Name (Legal Business Name): KURT HEALY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2016
Last Update Date: 01/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 E SUPERIOR ST
CHICAGO IL
60611-2654
US

IV. Provider business mailing address

1340 W NEWPORT AVE
CHICAGO IL
60657-1412
US

V. Phone/Fax

Practice location:
  • Phone: 312-238-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number056.011312
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: