Provider Demographics
NPI:1609045863
Name:HUMBOLDT PARK HEALTH
Entity Type:Organization
Organization Name:HUMBOLDT PARK HEALTH
Other - Org Name:PHYSICIAN SPECIALTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:CHERYL
Authorized Official - Last Name:ERINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-244-5256
Mailing Address - Street 1:1799 MOMENTUM PL
Mailing Address - Street 2:LOCK BOX 231799
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5317
Mailing Address - Country:US
Mailing Address - Phone:773-292-8200
Mailing Address - Fax:773-278-3899
Practice Address - Street 1:1044 N FRANCISCO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2743
Practice Address - Country:US
Practice Address - Phone:773-292-8200
Practice Address - Fax:773-278-3899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL000007296261Q00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01618185OtherBCBS
IL945301OtherGROUP