Provider Demographics
NPI:1376662544
Name:J. BOB ACHEBE MD SC
Entity Type:Organization
Organization Name:J. BOB ACHEBE MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BOB
Authorized Official - Last Name:ACHEBE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-333-5782
Mailing Address - Street 1:10810 S HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-3126
Mailing Address - Country:US
Mailing Address - Phone:773-785-9000
Mailing Address - Fax:
Practice Address - Street 1:10810 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-3126
Practice Address - Country:US
Practice Address - Phone:773-785-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036054592207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036054592Medicaid
IL21606987OtherBCBSIL
IL036054592Medicaid
IL492650Medicare PIN