Provider Demographics
NPI:1700136124
Name:MERCY FAMILY HEALTH CENTER @ LOWER WEST CLINIC
Entity Type:Organization
Organization Name:MERCY FAMILY HEALTH CENTER @ LOWER WEST CLINIC
Other - Org Name:MERCY DIAGNOSTIC & TREATMENT CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VP/CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:GARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-567-2000
Mailing Address - Street 1:2525 S. MICHIGAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2477
Mailing Address - Country:US
Mailing Address - Phone:312-567-7616
Mailing Address - Fax:312-328-7702
Practice Address - Street 1:1713 S. ASHLAND AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608
Practice Address - Country:US
Practice Address - Phone:312-746-5158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY FAMILY HEALTH CENTER FQHC SITE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2065063282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619918497OtherNPI