Provider Demographics
NPI:1710437991
Name:HOWARD BROWN HEALTH CENTER
Entity Type:Organization
Organization Name:HOWARD BROWN HEALTH CENTER
Other - Org Name:HOWARD BROWN HEALTH 55TH STREET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:BURGUNDY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:872-629-3491
Mailing Address - Street 1:4025 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2010
Mailing Address - Country:US
Mailing Address - Phone:773-388-1600
Mailing Address - Fax:
Practice Address - Street 1:1525 E 55TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-5512
Practice Address - Country:US
Practice Address - Phone:773-388-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOWARD BROWN HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-11
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
567250Medicare PIN