Provider Demographics
NPI:1922294503
Name:VIRU SC
Entity Type:Organization
Organization Name:VIRU SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-716-7281
Mailing Address - Street 1:2412 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-3155
Mailing Address - Country:US
Mailing Address - Phone:773-423-6178
Mailing Address - Fax:773-451-8285
Practice Address - Street 1:2412 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-3155
Practice Address - Country:US
Practice Address - Phone:773-423-6178
Practice Address - Fax:773-451-8285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-115930207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL159363Medicare UPIN