Provider Demographics
NPI:1720537384
Name:CHICAGOLAND PHYSICIAN CONSORTIUM, LLC
Entity Type:Organization
Organization Name:CHICAGOLAND PHYSICIAN CONSORTIUM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RUDYARD
Authorized Official - Middle Name:U
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-459-9661
Mailing Address - Street 1:3510 W 79TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60652-1430
Mailing Address - Country:US
Mailing Address - Phone:773-459-9661
Mailing Address - Fax:312-631-2892
Practice Address - Street 1:3510 W 79TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652-1430
Practice Address - Country:US
Practice Address - Phone:773-459-9661
Practice Address - Fax:312-631-2892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-23
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty