Provider Demographics
NPI:1326186941
Name:ST JUDE MEDICAL CLINIC SC
Entity Type:Organization
Organization Name:ST JUDE MEDICAL CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROMA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUKLA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:773-523-8773
Mailing Address - Street 1:3943 W 31ST ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-4936
Mailing Address - Country:US
Mailing Address - Phone:773-523-8773
Mailing Address - Fax:773-523-9259
Practice Address - Street 1:3943 W 31ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-4936
Practice Address - Country:US
Practice Address - Phone:773-523-8773
Practice Address - Fax:773-523-9259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-03
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty