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General NPI Number Information
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NPI Number | 1447418017
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Entity Type | Organization
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Legal Business Name | HEALTH DEPARTMENT
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Dates
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Enumeration Date | 05/29/2008
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Last Update Date | 05/29/2008
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Provider Practice Location Address
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Address Line | 5400 S HYDE PARK BLVD APT D2
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City | CHICAGO
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State | IL
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Zip | 60615-5852
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Country | US
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Telephone | 773-667-4631
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Fax |
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Provider Business Mailing Address
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Address Line | 5400 S HYDE PARK BLVD APT D2
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City | CHICAGO
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State | IL
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Zip | 60615-5852
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Country | US
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Telephone | 773-667-4631
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Fax |
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Authorized Official
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Title or Position | PEDIATRICIAN
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Name | MRS. PRATHIBHA V THARIMALA
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Credential | MD
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Telephone | 773-667-4631
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QC1500X
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Taxonomy Name | Community Health Clinic/Center
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License Number | 036048048
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License Number State | IL
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