Provider Demographics
NPI:1629128319
Name:PROGRESSIVE MEDICAL CENTER SC
Entity Type:Organization
Organization Name:PROGRESSIVE MEDICAL CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-238-9235
Mailing Address - Street 1:1841 W ARMY TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-1901
Mailing Address - Country:US
Mailing Address - Phone:630-238-9235
Mailing Address - Fax:630-620-0581
Practice Address - Street 1:414 W LAKE STREET
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101
Practice Address - Country:US
Practice Address - Phone:630-458-1905
Practice Address - Fax:630-458-1908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103673207Q00000X
IL036107571207Q00000X
IL036087152207R00000X
IL036078267208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036109448Medicaid
IL036078267Medicaid
IL036103673Medicaid
IL036087152Medicaid
IL2205538OtherBCBS OF ILLINOIS
IL036078267Medicaid
ILK14000Medicare ID - Type Unspecified
IL036103673Medicaid
IL036109448Medicaid
IL2205538OtherBCBS OF ILLINOIS
ILE40859Medicare UPIN
ILP00311497Medicare ID - Type Unspecified
IL373120Medicare ID - Type Unspecified
IL036078267Medicaid
IL036087152Medicaid
ILG05846Medicare UPIN
ILH53956Medicare UPIN
ILI24586Medicare UPIN
IL352610Medicare ID - Type Unspecified