Healthcare Provider Details

I. General information

NPI: 1508294091
Provider Name (Legal Business Name): SOUTH SHORE SCHOOL OF LEADERSHIP HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2013
Last Update Date: 10/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7627 S CONSTANCE AVE
CHICAGO IL
60649-4009
US

IV. Provider business mailing address

2850 S WABASH AVE SUITE 203
CHICAGO IL
60616-2955
US

V. Phone/Fax

Practice location:
  • Phone: 773-535-7406
  • Fax: 312-808-0655
Mailing address:
  • Phone: 312-808-0621
  • Fax: 312-808-0655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number042617358
License Number StateIL

VIII. Authorized Official

Name: DR. PETER FRIEDELL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 312-808-0621