Basic Information
| Provider Information | |||||||||
| NPI: | 1851712053 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ERIE FAMILY HEALTH CENTER INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ERIE WAUKEGAN HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2323 GRAND AVE | ||||||||
| Address2: | 2323 GRAND AVENUE | ||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600853312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126663494 | ||||||||
| FaxNumber: | 3126660610 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 W SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606225646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126663494 | ||||||||
| FaxNumber: | 3126660610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2013 | ||||||||
| LastUpdateDate: | 12/16/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NORENA | ||||||||
| AuthorizedOfficialFirstName: | GABRIELA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3124327444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1616827 | 01 | IL | BLUE CROSS BLUE SHIELDS | OTHER |