Provider Demographics
NPI:1487843496
Name:SAUGANASH HEALTH ASSOCIATES
Entity Type:Organization
Organization Name:SAUGANASH HEALTH ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-293-3510
Mailing Address - Street 1:2740 W FOSTER AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3500
Mailing Address - Country:US
Mailing Address - Phone:773-293-3510
Mailing Address - Fax:
Practice Address - Street 1:2740 W. FOSTER AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3599
Practice Address - Country:US
Practice Address - Phone:773-293-3510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN762360Medicare UPIN
IL698190Medicare UPIN