Provider Demographics
NPI:1720104573
Name:PCC COMMUNITY WELLNESS CENTER
Entity Type:Organization
Organization Name:PCC COMMUNITY WELLNESS CENTER
Other - Org Name:PCC MELROSE PARK FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:URSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-383-9786
Mailing Address - Street 1:1111 SUPERIOR ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-4138
Mailing Address - Country:US
Mailing Address - Phone:708-406-3040
Mailing Address - Fax:708-406-3059
Practice Address - Street 1:1111 SUPERIOR ST
Practice Address - Street 2:SUITE 207
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-4138
Practice Address - Country:US
Practice Address - Phone:708-406-3040
Practice Address - Fax:708-406-3059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL011261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========011Medicaid