Provider Demographics
NPI:1508294091
Name:SOUTH SHORE SCHOOL OF LEADERSHIP HEALTH CENTER
Entity Type:Organization
Organization Name:SOUTH SHORE SCHOOL OF LEADERSHIP HEALTH CENTER
Other - Org Name:FRIEDELL PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIEDELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-808-0621
Mailing Address - Street 1:2850 S WABASH AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2955
Mailing Address - Country:US
Mailing Address - Phone:312-808-0621
Mailing Address - Fax:312-808-0655
Practice Address - Street 1:7627 S CONSTANCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-4009
Practice Address - Country:US
Practice Address - Phone:773-535-7406
Practice Address - Fax:312-808-0655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-22
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042617358261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health