Provider Demographics
NPI:1245278233
Name:KIMBALL MEDICAL CENTER SC
Entity type:Organization
Organization Name:KIMBALL MEDICAL CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:TANDETER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-235-6266
Mailing Address - Street 1:2837 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-7403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2837 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-7403
Practice Address - Country:US
Practice Address - Phone:773-235-6266
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
966620Medicare PIN