Provider Demographics
NPI:1063560738
Name:INTERAMERICAN CLINICAL SERVICES
Entity type:Organization
Organization Name:INTERAMERICAN CLINICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANA
Authorized Official - Middle Name:E
Authorized Official - Last Name:CASTELLANOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-252-1147
Mailing Address - Street 1:PO BOX 470717
Mailing Address - Street 2:INTERAMERICAN CLINICAL SERVICES
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-0717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:773-252-5938
Practice Address - Street 1:2651 W DIVISION ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622
Practice Address - Country:US
Practice Address - Phone:773-252-1147
Practice Address - Fax:773-252-5938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL55812261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21621949Medicaid
IL308415Medicare ID - Type Unspecified
IL21621949Medicaid