Provider Demographics
NPI:1760572671
Name:AMERICAN INDIAN HEALTH SERVICE OF CHICAGO INC
Entity Type:Organization
Organization Name:AMERICAN INDIAN HEALTH SERVICE OF CHICAGO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LAVALLIE-UNABIA
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:773-883-9100
Mailing Address - Street 1:4326 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-2016
Mailing Address - Country:US
Mailing Address - Phone:773-883-9100
Mailing Address - Fax:773-883-0005
Practice Address - Street 1:4085 N BROADWAY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613
Practice Address - Country:US
Practice Address - Phone:773-883-9100
Practice Address - Fax:773-883-0005
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMERICAN INDIAN HEALTH SERVICE OF CHICAGO INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-13
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL209171Medicare PIN