Healthcare Provider Details

I. General information

NPI: 1316123961
Provider Name (Legal Business Name): COMMUNITY FAMILY MEDICINE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6307 S STEWART AVE STE 310
CHICAGO IL
60621-3116
US

IV. Provider business mailing address

6307 S STEWART AVE STE 310
CHICAGO IL
60621-3116
US

V. Phone/Fax

Practice location:
  • Phone: 773-487-3017
  • Fax: 773-487-3028
Mailing address:
  • Phone: 773-487-3017
  • Fax: 773-487-3028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number036067419
License Number StateIL

VIII. Authorized Official

Name: EDITH CHAFFIN
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 773-487-3017