Provider Demographics
NPI:1447265053
Name:CHICAGO MONTICELLO MEDICAL CTR
Entity type:Organization
Organization Name:CHICAGO MONTICELLO MEDICAL CTR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:EARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-722-6171
Mailing Address - Street 1:3623 W CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-3934
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3623 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-3934
Practice Address - Country:US
Practice Address - Phone:773-722-6171
Practice Address - Fax:773-722-7913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
1478723OtherOTHER ID NUMBER-COMMERCIAL NUMBER
1478723OtherOTHER ID NUMBER