Healthcare Provider Details

I. General information

NPI: 1053518720
Provider Name (Legal Business Name): 26TH STREET MEDICAL, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 03/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3814 W 26TH ST
CHICAGO IL
60623-3807
US

IV. Provider business mailing address

3814 W 26TH ST
CHICAGO IL
60623-3807
US

V. Phone/Fax

Practice location:
  • Phone: 773-522-5200
  • Fax: 773-522-5356
Mailing address:
  • Phone: 773-522-5200
  • Fax: 773-522-5356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateIL

VIII. Authorized Official

Name: MRS. ANNA SAUCEDO
Title or Position: OFFICE ADMINISTRATOR
Credential: BS
Phone: 773-522-5200