MEDICARE: NEAR NORTH HEALTH SERVICE CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1073594297
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEAR NORTH HEALTH SERVICE CORPORATION

Provider Business Mailing Address
First Line	:	1276 N CLYBOURN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-2089
Country	:	US
Telephone Number	:	312-337-1073
Fax Number	:	312-337-7616

Provider Business Practice Location Address
First Line	:	4829 S COTTAGE GROVE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-1600
Country	:	US
Telephone Number	:	773-548-1170
Fax Number	:	773-548-1404

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. BERNEICE MILLS-THOMAS
Credential	:
Telephone Number	:	312-337-1073

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	07/13/2021

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Directions to “NEAR NORTH HEALTH SERVICE CORPORATION ” Practice Location

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