Provider Demographics
NPI:1235327941
Name:S. DAVID DEMOREST
Entity Type:Organization
Organization Name:S. DAVID DEMOREST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:L
Authorized Official - Last Name:GIACCHINO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:708-343-2500
Mailing Address - Street 1:P. O BOX 1624
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160
Mailing Address - Country:US
Mailing Address - Phone:708-452-1200
Mailing Address - Fax:708-425-0157
Practice Address - Street 1:8383 BELMONT AVENUE
Practice Address - Street 2:
Practice Address - City:RIVER GROVE
Practice Address - State:IL
Practice Address - Zip Code:60171
Practice Address - Country:US
Practice Address - Phone:708-452-1200
Practice Address - Fax:708-452-0157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL737320OtherMEDICARE
IL0360677383Medicaid
IL737320OtherMEDICARE