Provider Demographics
NPI:1861044497
Name:JRHMD MEDICAL SC
Entity Type:Organization
Organization Name:JRHMD MEDICAL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-276-5212
Mailing Address - Street 1:9335 S LEAVITT ST # 231
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-6320
Mailing Address - Country:US
Mailing Address - Phone:855-276-5212
Mailing Address - Fax:
Practice Address - Street 1:6307 S STEWART AVE STE 203
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-3116
Practice Address - Country:US
Practice Address - Phone:312-504-8403
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-13
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036119430Medicaid