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NPI Code Detail

MEDICARE: NEAR NORTH HEALTH SERVICE CORPORATION

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
1261QF0400XFederally Qualified Health Center (FQHC)2307802IL

General Provider Information

NPI Number : 1720404494
Entity Type Code : Organization
Provider Name (Legal Business Name) : NEAR NORTH HEALTH SERVICE CORPORATION
Provider Business Mailing Address
First Line : 1520 N KOSTNER AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60651-1610
Country : US
Telephone Number : 312-337-1073
Fax Number : 312-337-7616
Provider Business Practice Location Address
First Line : 1520 N KOSTNER AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60651-1610
Country : US
Telephone Number : 312-337-1073
Fax Number : 312-337-7616
Authorized Official
Title or Position : CONTROLLER
Name : CUSH MVUDUDU
Credential :
Telephone Number : 312-337-1073
Provider Enumeration Date : 03/05/2014
Last Update Date : 01/27/2023

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Directions to “NEAR NORTH HEALTH SERVICE CORPORATION ” Practice Location

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