Provider Demographics
NPI:1740304757
Name:FULLERTON OCCUPATIONAL MEDICINE & IMMEDIATE CARE SC
Entity type:Organization
Organization Name:FULLERTON OCCUPATIONAL MEDICINE & IMMEDIATE CARE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RENLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:XIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-486-5001
Mailing Address - Street 1:3409 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-2415
Mailing Address - Country:US
Mailing Address - Phone:773-486-5001
Mailing Address - Fax:
Practice Address - Street 1:3409 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2415
Practice Address - Country:US
Practice Address - Phone:773-486-5001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL364061160261QP2000X, 261QU0200X, 261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088691 4Medicaid
IL01635426OtherOTHER
ILG21025Medicare UPIN