Provider Demographics
NPI:1558387167
Name:PCC COMMUNITY WELLNESS CENTER
Entity Type:Organization
Organization Name:PCC COMMUNITY WELLNESS CENTER
Other - Org Name:PCC DR. TONG HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:URSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-383-9786
Mailing Address - Street 1:1 ERIE COURT
Mailing Address - Street 2:STE 6040
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2510
Mailing Address - Country:US
Mailing Address - Phone:708-386-1301
Mailing Address - Fax:708-386-3053
Practice Address - Street 1:1 ERIE COURT
Practice Address - Street 2:STE 6040
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2510
Practice Address - Country:US
Practice Address - Phone:708-386-1301
Practice Address - Fax:708-386-3053
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PCC COMMUNITY WELLNESS CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL004261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
141034OtherMEDICARE PART A PROVIDER NUMBER
IL=========04Medicaid
328570Medicare ID - Type UnspecifiedGROUP
IL=========04Medicaid