Provider Demographics
NPI:1710296603
Name:AMERICAN HOSPITAL SERVICE CORPORATION
Entity Type:Organization
Organization Name:AMERICAN HOSPITAL SERVICE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRYK
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROZTOCZYNSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:773-745-8434
Mailing Address - Street 1:6157 W BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-4004
Mailing Address - Country:US
Mailing Address - Phone:773-745-8434
Mailing Address - Fax:773-745-3443
Practice Address - Street 1:6157 W BELMONT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4004
Practice Address - Country:US
Practice Address - Phone:773-745-8434
Practice Address - Fax:773-745-3443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-27
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058369261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036058369Medicaid
ILAR8609236OtherFDA
IL31600059OtherBCBS
IL14D0878232OtherCLIA
IL1457430415Medicare PIN
IL14D0878232OtherCLIA