Provider Demographics
NPI:1609899533
Name:CHILDRENS AND FAMILY HEALTH CLINIC
Entity Type:Organization
Organization Name:CHILDRENS AND FAMILY HEALTH CLINIC
Other - Org Name:CHILDRENS AND FAMILY HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:AZRA
Authorized Official - Middle Name:SHIBLI
Authorized Official - Last Name:SHERIFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-769-9070
Mailing Address - Street 1:205 E 86TH CT
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410
Mailing Address - Country:US
Mailing Address - Phone:219-769-9070
Mailing Address - Fax:219-769-1758
Practice Address - Street 1:205 E 86TH CT
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410
Practice Address - Country:US
Practice Address - Phone:219-769-9070
Practice Address - Fax:219-769-1758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032560207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100212430CMedicaid