Provider Demographics
NPI:1578603023
Name:MELROSE PARK CLINIC
Entity Type:Organization
Organization Name:MELROSE PARK CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:L
Authorized Official - Last Name:GACCLUNO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:708-343-2500
Mailing Address - Street 1:1252 WINSTON PLAZA
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160
Mailing Address - Country:US
Mailing Address - Phone:708-343-2500
Mailing Address - Fax:708-343-9545
Practice Address - Street 1:1252 WINSTON PLAZA
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160
Practice Address - Country:US
Practice Address - Phone:708-343-2500
Practice Address - Fax:708-343-9545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty