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General NPI Number Information
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NPI Number | 1659725133
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Entity Type | Organization
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Legal Business Name | NEAR NORTH HEALTH SERVICE CORPORATION
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Dates
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Enumeration Date | 04/20/2016
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Last Update Date | 10/15/2024
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Provider Practice Location Address
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Address Line | 4140 N BROADWAY ST
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City | CHICAGO
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State | IL
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Zip | 60613-2121
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Country | US
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Telephone | 773-878-8098
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Fax |
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Provider Business Mailing Address
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Address Line | 1276 N CLYBOURN AVE
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City | CHICAGO
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State | IL
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Zip | 60610-2089
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Country | US
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Telephone | 312-337-1073
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | TRISTE SMITH
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Credential |
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Telephone | 312-337-1073
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number |
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License Number State |
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