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General NPI Number Information
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NPI Number | 1093011702
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Entity Type | Organization
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Legal Business Name | JESSE BROWN VA MEDICAL CENTER
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Dates
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Enumeration Date | 01/28/2011
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Last Update Date | 01/28/2011
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Provider Practice Location Address
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Address Line | 820 S DAMEN AVE
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City | CHICAGO
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State | IL
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Zip | 60612-3728
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Country | US
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Telephone | 312-569-7271
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Fax |
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Provider Business Mailing Address
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Address Line | 6544 N LONGMEADOW AVE
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City | LINCOLNWOOD
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State | IL
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Zip | 60712-3206
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Country | US
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Telephone | 847-933-0093
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Fax |
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Authorized Official
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Title or Position | CONSULTANT
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Name | DR. S. JOSEPH MAURICE
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Credential | MD
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Telephone | 312-569-7271
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QV0200X
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Taxonomy Name | VA Clinic/Center
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License Number | 036037238
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License Number State | IL
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