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General NPI Number Information
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NPI Number | 1275068876
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Entity Type | Organization
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Legal Business Name | ST. BERNARD HOSPITAL AMBULATORY CARE CLINIC
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Dates
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Enumeration Date | 04/21/2017
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Last Update Date | 05/03/2017
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Provider Practice Location Address
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Address Line | 6307 S STEWART
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City | CHICAGO
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State | IL
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Zip | 60621
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Country | US
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Telephone | 773-962-3975
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Fax | 773-962-4252
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Provider Business Mailing Address
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Address Line | 7634 S PRAIRIE AVE
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City | CHICAGO
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State | IL
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Zip | 60619-2418
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Country | US
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Telephone | 773-962-3975
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Fax | 773-962-4252
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Authorized Official
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Title or Position | ADVANCED NURSE PRACTITIONER
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Name | MS. BIAISHA YUTRINA WASHINGTON
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Credential | NP-C
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Telephone | 773-962-3975
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 209.015904
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License Number State | IL
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