Provider Demographics
NPI:1417156043
Name:NEAR NORTH HEALTH SERVICE CORPORATION
Entity Type:Organization
Organization Name:NEAR NORTH HEALTH SERVICE CORPORATION
Other - Org Name:UPTOWN COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BERENICE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLS-THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-337-1073
Mailing Address - Street 1:1276 N CLYBOURN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-2089
Mailing Address - Country:US
Mailing Address - Phone:312-337-1073
Mailing Address - Fax:312-337-7616
Practice Address - Street 1:4867 N BROADWAY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:773-561-6640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)