Provider Demographics
NPI:1568758415
Name:MD @ HOME ILLINOIS, SC
Entity Type:Organization
Organization Name:MD @ HOME ILLINOIS, SC
Other - Org Name:MD AT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-243-2223
Mailing Address - Street 1:2003 W FULTON ST STE 303
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-2345
Mailing Address - Country:US
Mailing Address - Phone:312-243-2223
Mailing Address - Fax:312-243-2227
Practice Address - Street 1:2003 W FULTON ST STE 303
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-2345
Practice Address - Country:US
Practice Address - Phone:312-243-2223
Practice Address - Fax:312-243-2227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-20
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty