Provider Demographics
NPI:1194044743
Name:PROSPECT HEALTHCARE SC
Entity Type:Organization
Organization Name:PROSPECT HEALTHCARE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GARTRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-376-6317
Mailing Address - Street 1:2 E 22ND ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6106
Mailing Address - Country:US
Mailing Address - Phone:630-376-6317
Mailing Address - Fax:630-376-6319
Practice Address - Street 1:2 E 22ND ST
Practice Address - Street 2:SUITE 110
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-6106
Practice Address - Country:US
Practice Address - Phone:630-376-6317
Practice Address - Fax:630-376-6319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-21
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty