Healthcare Provider Details

I. General information

NPI: 1659324788
Provider Name (Legal Business Name): TELLEZ MEDICAL CENTER SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9206 S COMMERCIAL AVE
CHICAGO IL
60617-4508
US

IV. Provider business mailing address

PO BOX 967
TINLEY PARK IL
60477-0967
US

V. Phone/Fax

Practice location:
  • Phone: 773-978-0707
  • Fax:
Mailing address:
  • Phone: 708-532-6029
  • Fax: 708-468-4991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: JUAN L TELLEZ
Title or Position: CEO
Credential: MD
Phone: 773-978-0707