=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649721531
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHICAGO FAMILY HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2016
-----------------------------------------------------
Last Update Date | 10/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9119 S EXCHANGE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-4225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-768-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9119 S EXCHANGE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-4225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING AND MANAGED CARE SPEC
-----------------------------------------------------
Name | BRANDON TAYLOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-768-5000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------