MEDICARE: FULLERTON DRAKE MEDICAL CENTER

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	332900000X	Non-Pharmacy Dispensing Site

General Provider Information

NPI Number	:	1104693845
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULLERTON DRAKE MEDICAL CENTER

Provider Business Mailing Address
First Line	:	3518 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2418
Country	:	US
Telephone Number	:	773-278-0334
Fax Number	:

Provider Business Practice Location Address
First Line	:	3518 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2418
Country	:	US
Telephone Number	:	773-278-0334
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARK K GERBER
Credential	:	MD
Telephone Number	:	773-278-0334

Provider Enumeration Date	:	12/04/2023
Last Update Date	:	12/04/2023

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