=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396155669
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHICAGO FAMILY MEDICAL CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2014
-----------------------------------------------------
Last Update Date | 05/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1512 W CHICAGO AVE SUITE 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60642-5204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-495-3333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1512 W CHICAGO AVE SUITE 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60642-5204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-495-3333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MOHAMMED RIAZUDDIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 630-495-3333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 036065312
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------