Healthcare Provider Details

I. General information

NPI: 1306129556
Provider Name (Legal Business Name): PHYSICIANS COMMUNITY MEDICAL CENTER HAZEL CREST,S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2011
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 W 177TH ST
HAZEL CREST IL
60429-2184
US

IV. Provider business mailing address

5320 159TH ST
OAK FOREST IL
60452-4705
US

V. Phone/Fax

Practice location:
  • Phone: 708-798-8112
  • Fax: 708-535-6396
Mailing address:
  • Phone: 708-798-8112
  • Fax: 708-535-6396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. CHERISE LEE-SMITH
Title or Position: MEDICAL BILLING MANAGER
Credential:
Phone: 708-798-8112