Provider Demographics
NPI:1851464549
Name:PROGRESSIVE MEDICAL CENTER SC
Entity Type:Organization
Organization Name:PROGRESSIVE MEDICAL CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-238-9235
Mailing Address - Street 1:229 W GRAND AVENUE
Mailing Address - Street 2:SUITE R
Mailing Address - City:BENSENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60106-3365
Mailing Address - Country:US
Mailing Address - Phone:630-238-9235
Mailing Address - Fax:630-238-0426
Practice Address - Street 1:229 W GRAND AVE
Practice Address - Street 2:SUITE R
Practice Address - City:BENSENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60106-3399
Practice Address - Country:US
Practice Address - Phone:630-238-9235
Practice Address - Fax:630-238-0426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103673207Q00000X
IL036087152207R00000X
IL036078267208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103673Medicaid
IL036109448Medicaid
IL036078267Medicaid
IL036087152Medicaid
IL02205538OtherBCBS GROUP NUMBER
IL036078267Medicaid
IL036103673Medicaid
IL110153600Medicare ID - Type UnspecifiedRAILROADCARRIER DR HENRIQ
IL036078267Medicaid
IL036109448Medicaid
ILP00311497Medicare ID - Type UnspecifiedRAILROADCARRIER DR BURGOS
IL110153602Medicare ID - Type UnspecifiedRAILROADCARRIER DR NUNEZ
ILG05846Medicare UPIN
ILH53956Medicare UPIN
ILCF9448Medicare ID - Type UnspecifiedRAILROADCARRIER GROUP#
IL937192Medicare ID - Type UnspecifiedDR NUNEZ
IL200566Medicare ID - Type UnspecifiedDR BURGOS
ILK14000Medicare ID - Type UnspecifiedDR LOPEZ
IL373120Medicare ID - Type UnspecifiedGROUP NUMBER