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General NPI Number Information
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NPI Number | 1104693845
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Entity Type | Organization
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Legal Business Name | FULLERTON DRAKE MEDICAL CENTER
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Dates
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Enumeration Date | 12/04/2023
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Last Update Date | 12/04/2023
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Provider Practice Location Address
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Address Line | 3518 W FULLERTON AVE
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City | CHICAGO
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State | IL
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Zip | 60647-2418
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Country | US
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Telephone | 773-278-0334
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Fax |
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Provider Business Mailing Address
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Address Line | 3518 W FULLERTON AVE
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City | CHICAGO
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State | IL
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Zip | 60647-2418
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Country | US
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Telephone | 773-278-0334
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARK K GERBER
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Credential | MD
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Telephone | 773-278-0334
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number |
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License Number State |
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