Provider Demographics
NPI:1124298492
Name:CIRCLE FAMILY CARE
Entity type:Organization
Organization Name:CIRCLE FAMILY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:REUBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTIFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-379-1000
Mailing Address - Street 1:5002 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644-4127
Mailing Address - Country:US
Mailing Address - Phone:773-379-1000
Mailing Address - Fax:773-379-1342
Practice Address - Street 1:4909 W DIVISION ST
Practice Address - Street 2:SUITE 307
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-3161
Practice Address - Country:US
Practice Address - Phone:773-379-1000
Practice Address - Fax:773-379-1342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========011Medicaid