Provider Demographics
NPI:1881890333
Name:PROVIDA HEALTH CENTER SC
Entity type:Organization
Organization Name:PROVIDA HEALTH CENTER SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:I
Authorized Official - Last Name:SALAZAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-548-2200
Mailing Address - Street 1:1425 N HUNT CLUB RD STE 100
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-2632
Mailing Address - Country:US
Mailing Address - Phone:847-548-2200
Mailing Address - Fax:847-548-2865
Practice Address - Street 1:1425 N HUNT CLUB RD STE 100
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031
Practice Address - Country:US
Practice Address - Phone:847-548-2200
Practice Address - Fax:847-548-2865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042616958207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04923018OtherBCBS NUMBER
IL042616958OtherCORPORATE IL LICENSE
IL546940Medicare PIN