Healthcare Provider Details

I. General information

NPI: 1538497656
Provider Name (Legal Business Name): CHICAGO UPTOWN MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 02/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10004 KENNERLY RD STE 335A
SAINT LOUIS MO
63128-2194
US

IV. Provider business mailing address

2333 W IRVING PARK RD
CHICAGO IL
60618-3838
US

V. Phone/Fax

Practice location:
  • Phone: 773-506-7340
  • Fax: 773-506-7341
Mailing address:
  • Phone: 773-506-7340
  • Fax: 773-506-7341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number2006013537
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2006013537
License Number StateMO

VIII. Authorized Official

Name: MS. LEJLA M. SUNJE
Title or Position: OFFICE MANAGER
Credential: MBA
Phone: 773-506-7340