Provider Demographics
NPI:1336516780
Name:FAMILY DOCTOR MEDICAL CENTER
Entity Type:Organization
Organization Name:FAMILY DOCTOR MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:773-940-1612
Mailing Address - Street 1:1918 W IRVING PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2408
Mailing Address - Country:US
Mailing Address - Phone:773-940-1612
Mailing Address - Fax:
Practice Address - Street 1:1918 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2408
Practice Address - Country:US
Practice Address - Phone:773-940-1612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY DOC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101658261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL20000890Medicaid
IL702060Medicare UPIN
ILH16264Medicare PIN