Healthcare Provider Details

I. General information

NPI: 1730310251
Provider Name (Legal Business Name): MERCY PHILLIPS HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2009
Last Update Date: 07/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 E PERSHING RD
CHICAGO IL
60653-2222
US

IV. Provider business mailing address

244 E PERSHING RD
CHICAGO IL
60653-2222
US

V. Phone/Fax

Practice location:
  • Phone: 312-567-7058
  • Fax: 312-328-7982
Mailing address:
  • Phone: 312-567-7058
  • Fax: 312-328-7982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number0001578
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number771115016
License Number StateIL

VIII. Authorized Official

Name: MRS. PATRICE KATHLEEN GRIFFIN
Title or Position: DELEGATED OFFICIAL
Credential:
Phone: 312-567-5593