Healthcare Provider Details

I. General information

NPI: 1548024755
Provider Name (Legal Business Name): PROVIDER SERVICES AT ST BERNARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2024
Last Update Date: 02/08/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 W 64TH ST
CHICAGO IL
60621-3146
US

IV. Provider business mailing address

326 W 64TH ST
CHICAGO IL
60621-3146
US

V. Phone/Fax

Practice location:
  • Phone: 773-962-4044
  • Fax: 773-962-4480
Mailing address:
  • Phone: 773-962-4044
  • Fax: 773-962-4480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT C SPRINGER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 773-962-4210