Provider Demographics
NPI:1174710255
Name:CHICAGO MEDICAL CENTER,SC
Entity type:Organization
Organization Name:CHICAGO MEDICAL CENTER,SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNTEANU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-248-0300
Mailing Address - Street 1:PO BOX 597781
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-7781
Mailing Address - Country:US
Mailing Address - Phone:773-248-0300
Mailing Address - Fax:
Practice Address - Street 1:4112 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-3028
Practice Address - Country:US
Practice Address - Phone:773-248-0300
Practice Address - Fax:773-248-0303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03609939Medicaid
IL03609939Medicaid
IL208808Medicare PIN