Healthcare Provider Details

I. General information

NPI: 1558593947
Provider Name (Legal Business Name): KEDZIE MEDICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2009
Last Update Date: 08/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 N KEDZIE AVE
CHICAGO IL
60612-1869
US

IV. Provider business mailing address

262 N KEDZIE AVE
CHICAGO IL
60612-1869
US

V. Phone/Fax

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

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: GOHAR AKOPYAN
Title or Position: CMM
Credential:
Phone: 847-904-7500