MEDICARE: ROGERS PARK FAMILY MEDICINE, SC.

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	036096295	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	214060	OTHER	IL	MEDICARE PROVIDER ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01636575	OTHER	IL	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740391549
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROGERS PARK FAMILY MEDICINE, SC.

Provider Business Mailing Address
First Line	:	2306 W TOUHY AVE STE C1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-3473
Country	:	US
Telephone Number	:	773-262-7000
Fax Number	:	773-262-7002

Provider Business Practice Location Address
First Line	:	2306 W TOUHY AVE # C1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-3414
Country	:	US
Telephone Number	:	773-262-7000
Fax Number	:	773-262-7002

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JAMES P CLANCY
Credential	:	MD
Telephone Number	:	773-262-7000

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	10/10/2014

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Directions to “ROGERS PARK FAMILY MEDICINE, SC. ” Practice Location

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