Provider Demographics
NPI:1578755179
Name:FRIEND FAMILY HEALTH CENTER- BEETHOVEN
Entity Type:Organization
Organization Name:FRIEND FAMILY HEALTH CENTER- BEETHOVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SABRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-702-5821
Mailing Address - Street 1:800 E 55TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4906
Mailing Address - Country:US
Mailing Address - Phone:773-702-0660
Mailing Address - Fax:773-702-4356
Practice Address - Street 1:25 W 47TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-4627
Practice Address - Country:US
Practice Address - Phone:773-702-0660
Practice Address - Fax:773-702-4356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========003Medicaid