Provider Demographics
NPI:1558593947
Name:KEDZIE MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:KEDZIE MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMM
Authorized Official - Prefix:
Authorized Official - First Name:GOHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:AKOPYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-904-7500
Mailing Address - Street 1:262 N KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-1869
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:262 N KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-1869
Practice Address - Country:US
Practice Address - Phone:847-904-7500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty