Provider Demographics
NPI:1639306640
Name:OTERO MEDICAL CENTER, S.C.
Entity Type:Organization
Organization Name:OTERO MEDICAL CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:OTERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-772-4900
Mailing Address - Street 1:4911 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-2505
Mailing Address - Country:US
Mailing Address - Phone:773-772-4900
Mailing Address - Fax:773-772-0298
Practice Address - Street 1:4911 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-2505
Practice Address - Country:US
Practice Address - Phone:773-772-4900
Practice Address - Fax:773-772-0298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-17
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1588776884OtherNPI INDIVIDUAL NUMBER
IL01626950OtherBLUE CROSS BLUE SHIELD OF ILLINOIS
IL036102552Medicaid
IL036102552Medicaid
IL01626950OtherBLUE CROSS BLUE SHIELD OF ILLINOIS