Healthcare Provider Details

I. General information

NPI: 1013239672
Provider Name (Legal Business Name): MICHIGAN AVENUE PRIMARY CARE, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2010
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 N MICHIGAN AVE SUITE 1605
CHICAGO IL
60601-7478
US

IV. Provider business mailing address

180 N MICHIGAN AVE SUITE 1605
CHICAGO IL
60601-7478
US

V. Phone/Fax

Practice location:
  • Phone: 312-201-1234
  • Fax: 312-201-1202
Mailing address:
  • Phone: 312-201-1234
  • Fax: 312-201-1202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES A RUNKE
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 312-201-1234