Basic Information
| Provider Information | |||||||||
| NPI: | 1194725192 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF CHICAGO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHICAGO DEPARTMENT OF PUBLIC HEALTH REVENUE 3200 | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 333 S STATE ST | ||||||||
| Address2: | REVENUE 200 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606043900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127479443 | ||||||||
| FaxNumber: | 3127479447 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 S STATE ST | ||||||||
| Address2: | REVENUE 200 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606043900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127479443 | ||||||||
| FaxNumber: | 3127479447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2005 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | SARAI | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REVENUE | ||||||||
| AuthorizedOfficialTelephone: | 3127479443 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
No ID Information.