Provider Demographics
NPI:1306851233
Name:CHICAGO COMMUNITY MEDICAL CENTER
Entity Type:Organization
Organization Name:CHICAGO COMMUNITY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:PREM
Authorized Official - Middle Name:LATA
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-978-5900
Mailing Address - Street 1:155 HARBOR POINT #5212
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7381
Mailing Address - Country:US
Mailing Address - Phone:773-978-5900
Mailing Address - Fax:773-978-7656
Practice Address - Street 1:2404 EAST 79TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-5112
Practice Address - Country:US
Practice Address - Phone:773-978-5900
Practice Address - Fax:773-978-7656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL468490Medicare ID - Type Unspecified
D12499Medicare UPIN