Basic Information
| Provider Information | |||||||||
| NPI: | 1821159625 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 31ST STD CLINIC | ||||||||
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| OtherOrganizationName: | 31ST STREET SEXUALLY TRANSMITTED DISEASES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | 3127479792 | ||||||||
| FaxNumber: | 3127479447 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 E 31ST ST | ||||||||
| Address2: | STD 31ST STREET CLINIC | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606164008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127479792 | ||||||||
| FaxNumber: | 3127479447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | SARAI | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REVENUE | ||||||||
| AuthorizedOfficialTelephone: | 3127479792 | ||||||||
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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 | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine |
No ID Information.