Provider Demographics
NPI:1740417153
Name:HUMBOLDT PARK HEALTH
Entity type:Organization
Organization Name:HUMBOLDT PARK HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:CHERYL
Authorized Official - Last Name:ERINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-244-5256
Mailing Address - Street 1:1044 N FRANCISCO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2743
Mailing Address - Country:US
Mailing Address - Phone:773-292-8200
Mailing Address - Fax:773-278-3899
Practice Address - Street 1:1044 N FRANCISCO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622
Practice Address - Country:US
Practice Address - Phone:773-292-8200
Practice Address - Fax:773-278-3899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-12
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicaid