Provider Demographics
NPI:1740391549
Name:ROGERS PARK FAMILY MEDICINE, SC.
Entity Type:Organization
Organization Name:ROGERS PARK FAMILY MEDICINE, SC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:CLANCY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-262-7000
Mailing Address - Street 1:2306 W TOUHY AVE STE C1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-3473
Mailing Address - Country:US
Mailing Address - Phone:773-262-7000
Mailing Address - Fax:773-262-7002
Practice Address - Street 1:2306 W TOUHY AVE # C1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-3414
Practice Address - Country:US
Practice Address - Phone:773-262-7000
Practice Address - Fax:773-262-7002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036096295207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01636575OtherBLUE CROSS BLUE SHIELD
IL036096295Medicaid
IL214060OtherMEDICARE PROVIDER ID
ILG86807Medicare UPIN