MEDICARE: ASIAN VILLAGE MEDICAL CLINIC PC

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	261Q00000X	Clinic/Center	036089675	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548436892
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASIAN VILLAGE MEDICAL CLINIC PC

Provider Business Mailing Address
First Line	:	5129 N BROADWAY ST
Second Line	:	SUITE E
City	:	CHICAGO
State	:	IL
Zip	:	60640-3018
Country	:	US
Telephone Number	:	774-275-4250
Fax Number	:	773-275-4263

Provider Business Practice Location Address
First Line	:	5129 N BROADWAY ST
Second Line	:	SUITE E
City	:	CHICAGO
State	:	IL
Zip	:	60640-3018
Country	:	US
Telephone Number	:	774-275-4250
Fax Number	:	773-275-4263

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PHUONG TRAN
Credential	:	MD
Telephone Number	:	773-275-4250

Provider Enumeration Date	:	05/07/2008
Last Update Date	:	09/30/2010

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