Provider Demographics
NPI:1972624799
Name:PRIMARY CARE PROVIDERS OF CHICAGO SC
Entity Type:Organization
Organization Name:PRIMARY CARE PROVIDERS OF CHICAGO SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-631-0566
Mailing Address - Street 1:7447 W TALCOTT AVE
Mailing Address - Street 2:SUITE 216
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3745
Mailing Address - Country:US
Mailing Address - Phone:773-631-0566
Mailing Address - Fax:773-631-4436
Practice Address - Street 1:7447 W TALCOTT AVE
Practice Address - Street 2:SUITE 216
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3745
Practice Address - Country:US
Practice Address - Phone:773-631-0566
Practice Address - Fax:773-631-4436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095721207Q00000X
IL036133839207Q00000X
IL036100881207R00000X
IL207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL693170Medicare PIN
IL693170Medicare PIN