Provider Demographics
NPI:1659324788
Name:TELLEZ MEDICAL CENTER SC
Entity Type:Organization
Organization Name:TELLEZ MEDICAL CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:TELLEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-978-0707
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-0967
Mailing Address - Country:US
Mailing Address - Phone:708-532-6029
Mailing Address - Fax:708-468-4991
Practice Address - Street 1:9206 S COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-4508
Practice Address - Country:US
Practice Address - Phone:773-978-0707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL574230Medicare ID - Type Unspecified