Healthcare Provider Details

I. General information

NPI: 1821159625
Provider Name (Legal Business Name): 31ST STD CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 E 31ST ST STD 31ST STREET CLINIC
CHICAGO IL
60616-4008
US

IV. Provider business mailing address

333 S STATE STREET REVENUE #200 CHICAGO DEPARTMENT OF PUBLIC HEALTH
CHICAGO IL
60604
US

V. Phone/Fax

Practice location:
  • Phone: 312-747-9792
  • Fax: 312-747-9447
Mailing address:
  • Phone: 312-747-9792
  • Fax: 312-747-9447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SARAI M JACKSON
Title or Position: DIRECTOR OF REVENUE
Credential: DIRECTOR
Phone: 312-747-9792