Healthcare Provider Details

I. General information

NPI: 1548492234
Provider Name (Legal Business Name): 63RD ADVANCED HEALTH CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2009
Last Update Date: 08/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1249 W 63RD ST
CHICAGO IL
60636-1947
US

IV. Provider business mailing address

1249 W 63RD ST
CHICAGO IL
60636-1947
US

V. Phone/Fax

Practice location:
  • Phone: 847-904-7500
  • Fax: 847-904-7502
Mailing address:
  • Phone: 847-904-7500
  • Fax: 847-904-7502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ALESIA CHAIKA
Title or Position: OWNER
Credential:
Phone: 847-904-7500