=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720776321
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMERICAN INDIAN HEALTH SERVICE OF CHICAGO INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2023
-----------------------------------------------------
Last Update Date | 12/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4326 W MONTROSE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60641-2016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-883-9100
-----------------------------------------------------
Fax | 773-883-0005
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4326 W MONTROSE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60641-2016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-883-9100
-----------------------------------------------------
Fax | 773-883-0005
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | QAQI/RISK MANAGMENT
-----------------------------------------------------
Name | SHARON HOLT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-883-9100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------