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General NPI Number Information
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NPI Number | 1326186941
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Entity Type | Organization
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Legal Business Name | ST JUDE MEDICAL CLINIC SC
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Dates
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Enumeration Date | 02/03/2007
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Last Update Date | 01/27/2020
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Provider Practice Location Address
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Address Line | 3943 W 31ST ST
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City | CHICAGO
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State | IL
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Zip | 60623-4936
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Country | US
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Telephone | 773-523-8773
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Fax | 773-523-9259
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Provider Business Mailing Address
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Address Line | 3943 W 31ST ST
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City | CHICAGO
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State | IL
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Zip | 60623-4936
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Country | US
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Telephone | 773-523-8773
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Fax | 773-523-9259
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Authorized Official
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Title or Position | MANAGER
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Name | MRS. ROMA SHUKLA
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Credential | DO
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Telephone | 773-523-8773
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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