Healthcare Provider Details

I. General information

NPI: 1073594297
Provider Name (Legal Business Name): NEAR NORTH HEALTH SERVICE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4829 S COTTAGE GROVE AVE
CHICAGO IL
60615-1600
US

IV. Provider business mailing address

1276 N CLYBOURN AVE
CHICAGO IL
60610-2089
US

V. Phone/Fax

Practice location:
  • Phone: 773-548-1170
  • Fax: 773-548-1404
Mailing address:
  • Phone: 312-337-1073
  • Fax: 312-337-7616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MRS. BERNEICE MILLS-THOMAS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 312-337-1073