MEDICARE: PCC COMMUNITY WELLNESS 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	261QF0400X	Federally Qualified Health Center (FQHC)	004	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	141034	OTHER		MEDICARE PART A PROVIDER NUMBER

General Provider Information

NPI Number	:	1558387167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PCC COMMUNITY WELLNESS CENTER

Provider Business Mailing Address
First Line	:	1 ERIE COURT
Second Line	:	STE 6040
City	:	OAK PARK
State	:	IL
Zip	:	60302-2510
Country	:	US
Telephone Number	:	708-386-1301
Fax Number	:	708-386-3053

Provider Business Practice Location Address
First Line	:	1 ERIE COURT
Second Line	:	STE 6040
City	:	OAK PARK
State	:	IL
Zip	:	60302-2510
Country	:	US
Telephone Number	:	708-386-1301
Fax Number	:	708-386-3053

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	ROBERT J URSO
Credential	:
Telephone Number	:	708-383-9786

Provider Enumeration Date	:	07/15/2006
Last Update Date	:	07/21/2022

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Directions to “PCC COMMUNITY WELLNESS CENTER ” Practice Location

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