Provider Demographics
NPI:1538497656
Name:CHICAGO UPTOWN MEDICAL CENTER
Entity Type:Organization
Organization Name:CHICAGO UPTOWN MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LEJLA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SUNJE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:773-506-7340
Mailing Address - Street 1:2333 W IRVING PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3838
Mailing Address - Country:US
Mailing Address - Phone:773-506-7340
Mailing Address - Fax:773-506-7341
Practice Address - Street 1:10004 KENNERLY RD STE 335A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2194
Practice Address - Country:US
Practice Address - Phone:773-506-7340
Practice Address - Fax:773-506-7341
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHICAGO UPTOWN MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-01
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006013537202K00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA2118Medicare PIN