Provider Demographics
NPI:1275068876
Name:ST. BERNARD HOSPITAL AMBULATORY CARE CLINIC
Entity Type:Organization
Organization Name:ST. BERNARD HOSPITAL AMBULATORY CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADVANCED NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:BIAISHA
Authorized Official - Middle Name:YUTRINA
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:773-962-3975
Mailing Address - Street 1:7634 S PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-2418
Mailing Address - Country:US
Mailing Address - Phone:773-962-3975
Mailing Address - Fax:773-962-4252
Practice Address - Street 1:6307 S STEWART
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621
Practice Address - Country:US
Practice Address - Phone:773-962-3975
Practice Address - Fax:773-962-4252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-21
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.015904261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center