Provider Demographics
NPI:1114909363
Name:ANNIE JOHN, M.D.S.C.
Entity Type:Organization
Organization Name:ANNIE JOHN, M.D.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-989-3977
Mailing Address - Street 1:P. O. BOX 2248
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60132-2248
Mailing Address - Country:US
Mailing Address - Phone:847-676-0091
Mailing Address - Fax:847-676-2374
Practice Address - Street 1:3434 W PETERSON AVE
Practice Address - Street 2:1A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3319
Practice Address - Country:US
Practice Address - Phone:773-583-5803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-003580164W00000X
IL036-068169207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036068169Medicaid
IL036068169Medicaid