Healthcare Provider Details

I. General information

NPI: 1295947430
Provider Name (Legal Business Name): COMMUNITYHEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 W CHICAGO AVE
CHICAGO IL
60622-4519
US

IV. Provider business mailing address

2611 W CHICAGO AVE
CHICAGO IL
60622-4519
US

V. Phone/Fax

Practice location:
  • Phone: 773-395-9901
  • Fax: 773-395-9902
Mailing address:
  • Phone: 773-395-9901
  • Fax: 773-395-9902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: TONY BONGIORNO
Title or Position: DIRECTOR OF PHARMACY OPERATIONS
Credential: PHARMD
Phone: 773-395-9901