Provider Demographics
NPI:1174658694
Name:MICHIGAN AVENUE IMMEDIATE CARE
Entity Type:Organization
Organization Name:MICHIGAN AVENUE IMMEDIATE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUNKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-201-1234
Mailing Address - Street 1:180 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 1605
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7478
Mailing Address - Country:US
Mailing Address - Phone:312-201-1234
Mailing Address - Fax:312-201-1202
Practice Address - Street 1:180 N MICHIGAN AVE
Practice Address - Street 2:SUITE 1605
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7478
Practice Address - Country:US
Practice Address - Phone:312-201-1234
Practice Address - Fax:312-201-1202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042.616731207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD16018Medicare UPIN