Basic Information
| Provider Information | |||||||||
| NPI: | 1194910125 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHICAGO DEPT OF PUBLIC HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 S STATE STREET | ||||||||
| Address2: | REVENUE #200 CHICAGO DEPARTMENT OF PUBLIC HEALTH | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127479443 | ||||||||
| FaxNumber: | 3127479447 | ||||||||
| Practice Location | |||||||||
| Address1: | 2849 N CLARK ST | ||||||||
| Address2: | LAKEVIEW N H C | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127447448 | ||||||||
| FaxNumber: | 3127479447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2007 | ||||||||
| LastUpdateDate: | 09/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | SARA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REVENUE | ||||||||
| AuthorizedOfficialTelephone: | 3127479443 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DIRECTOR | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0901X | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine |
No ID Information.