MEDICARE: CHICAGO COMMUNITY 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	207Q00000X	Family Medicine Physician		IL

General Provider Information

NPI Number	:	1306851233
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO COMMUNITY MEDICAL CENTER

Provider Business Mailing Address
First Line	:	155 HARBOR POINT #5212
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60601-7381
Country	:	US
Telephone Number	:	773-978-5900
Fax Number	:	773-978-7656

Provider Business Practice Location Address
First Line	:	2404 EAST 79TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-5112
Country	:	US
Telephone Number	:	773-978-5900
Fax Number	:	773-978-7656

Authorized Official
Title or Position	:	TREASURER
Name	:	PREM LATA PAUL
Credential	:	MD
Telephone Number	:	773-978-5900

Provider Enumeration Date	:	07/29/2006
Last Update Date	:	08/22/2020

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Directions to “CHICAGO COMMUNITY MEDICAL CENTER ” Practice Location

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