Provider Demographics
NPI:1932114386
Name:CALIFORNIA DEVON MEDICAL CENTER
Entity Type:Organization
Organization Name:CALIFORNIA DEVON MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GUREVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-973-6100
Mailing Address - Street 1:6420 N CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-5253
Mailing Address - Country:US
Mailing Address - Phone:773-973-6100
Mailing Address - Fax:773-262-4882
Practice Address - Street 1:6420 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-5253
Practice Address - Country:US
Practice Address - Phone:773-973-6100
Practice Address - Fax:773-262-4882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL769910Medicare ID - Type UnspecifiedGROUP
IL1252570001Medicare NSC