Provider Demographics
NPI:1689899551
Name:HOLY FAMILY MEDICAL CLINIC
Entity Type:Organization
Organization Name:HOLY FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PASCUAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-780-7400
Mailing Address - Street 1:4941 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-1419
Mailing Address - Country:US
Mailing Address - Phone:708-780-7400
Mailing Address - Fax:
Practice Address - Street 1:4941 W 14TH ST
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-1419
Practice Address - Country:US
Practice Address - Phone:708-780-7400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067770208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0031601680OtherBCBS
IL036067770Medicaid
IL=========OtherINSURANCE