Provider Demographics
NPI:1093011702
Name:JESSE BROWN VA MEDICAL CENTER
Entity Type:Organization
Organization Name:JESSE BROWN VA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:DR
Authorized Official - First Name:S. JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:MAURICE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-569-7271
Mailing Address - Street 1:6544 N LONGMEADOW AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-3206
Mailing Address - Country:US
Mailing Address - Phone:847-933-0093
Mailing Address - Fax:
Practice Address - Street 1:820 S DAMEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3728
Practice Address - Country:US
Practice Address - Phone:312-569-7271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-28
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036037238261QV0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA