Provider Demographics
NPI:1639277114
Name:ENRICA ROSSI MD SC CORPORATION
Entity Type:Organization
Organization Name:ENRICA ROSSI MD SC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ENRICA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-371-3588
Mailing Address - Street 1:333 W NORTH AVE
Mailing Address - Street 2:#290
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-1293
Mailing Address - Country:US
Mailing Address - Phone:312-371-3588
Mailing Address - Fax:
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:312-371-3588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095803207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095803Medicaid
IL036095803Medicaid