Provider Demographics
NPI:1023723087
Name:NORTHWEST MORTON GROVE SC
Entity type:Organization
Organization Name:NORTHWEST MORTON GROVE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANAND
Authorized Official - Middle Name:
Authorized Official - Last Name:THAKKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:224-233-0299
Mailing Address - Street 1:PO BOX 10417
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01041-2017
Mailing Address - Country:US
Mailing Address - Phone:224-530-1020
Mailing Address - Fax:
Practice Address - Street 1:6841 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-2628
Practice Address - Country:US
Practice Address - Phone:224-233-0299
Practice Address - Fax:224-233-0288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care