Provider Demographics
NPI:1700144243
Name:ERIE FAMILY HEALTH CENTER INC
Entity Type:Organization
Organization Name:ERIE FAMILY HEALTH CENTER INC
Other - Org Name:ERIE DIVISION STREET HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PATIENT ACCOUNT SUPERVISOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:GABRIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:NORENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-432-7444
Mailing Address - Street 1:1701 W SUPERIOR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-5646
Mailing Address - Country:US
Mailing Address - Phone:312-666-3494
Mailing Address - Fax:312-666-0610
Practice Address - Street 1:2418 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2940
Practice Address - Country:US
Practice Address - Phone:312-666-3494
Practice Address - Fax:312-666-0610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL748480OtherMEDICARE
IL1616827OtherBLUE CROSS BLUE SHIELD