Provider Demographics
NPI:1407043912
Name:ERIE FAMILY HEALTH CENTER, INC
Entity Type:Organization
Organization Name:ERIE FAMILY HEALTH CENTER, INC
Other - Org Name:HUMBOLDT PARK FAMILY HLTH CTR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING DEPARTMENT SUPERVISOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:GABRIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:NORENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-432-7444
Mailing Address - Street 1:1701 W SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-5646
Mailing Address - Country:US
Mailing Address - Phone:312-666-3494
Mailing Address - Fax:
Practice Address - Street 1:2750 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5247
Practice Address - Country:US
Practice Address - Phone:312-666-3494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL748480OtherMEDICARE PART B
IL1616827OtherBLUE CROSS BLUE SHIELD PROVIDER NUMBER
IL1616827OtherBLUE CROSS BLUE SHIELD PROVIDER NUMBER
IL141835Medicare PIN