Provider Demographics
NPI:1912200882
Name:OBREGON MEDICAL CENTER INC
Entity Type:Organization
Organization Name:OBREGON MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:FELIX
Authorized Official - Middle Name:
Authorized Official - Last Name:OBREGON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-656-8775
Mailing Address - Street 1:5533 W CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-2236
Mailing Address - Country:US
Mailing Address - Phone:708-656-8775
Mailing Address - Fax:
Practice Address - Street 1:5533 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2236
Practice Address - Country:US
Practice Address - Phone:708-656-8775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-14
Last Update Date:2011-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069552207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036069552Medicaid
IL036069552Medicaid