Provider Demographics
NPI:1629022058
Name:SOUTHTOWN MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHTOWN MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VENKATA
Authorized Official - Middle Name:A
Authorized Official - Last Name:VALLURY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-284-8601
Mailing Address - Street 1:6342 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4706
Mailing Address - Country:US
Mailing Address - Phone:773-284-8601
Mailing Address - Fax:
Practice Address - Street 1:6342 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4706
Practice Address - Country:US
Practice Address - Phone:773-284-8601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036069911Medicaid
IL036101348Medicaid
IL1174528061OtherMEDICARE NPI
IL1356346241OtherMEDICARE NPI
IL1634276OtherBCBS
IL036101348Medicaid
IL1356346241OtherMEDICARE NPI
IL1174528061OtherMEDICARE NPI