Provider Demographics
NPI:1578793816
Name:CENTER FOR FAMILY HEALTH
Entity Type:Organization
Organization Name:CENTER FOR FAMILY HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:POORTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-756-1521
Mailing Address - Street 1:165 E PLANK RD
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-8757
Mailing Address - Country:US
Mailing Address - Phone:815-752-3253
Mailing Address - Fax:815-752-3277
Practice Address - Street 1:165 E PLANK RD
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-8757
Practice Address - Country:US
Practice Address - Phone:815-752-3253
Practice Address - Fax:815-752-3277
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KISHHEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-21
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2556Medicare PIN