Basic Information
Provider Information
NPI: 1215407812
EntityType: 2
ReplacementNPI:  
OrganizationName: ILLINOIS URGENT CARE PROFESSIONALS PLLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: ON DMED URGENT CARE
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 17960 HALSTED ST
Address2:  
City: HOMEWOOD
State: IL
PostalCode: 604302014
CountryCode: US
TelephoneNumber: 8479339200
FaxNumber: 7734397715
Practice Location
Address1: 17960 HALSTED ST
Address2:  
City: HOMEWOOD
State: IL
PostalCode: 604302014
CountryCode: US
TelephoneNumber: 8479339200
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/27/2018
LastUpdateDate: 06/02/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: KHAN
AuthorizedOfficialFirstName: NOORUN
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 8479339200
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate: 06/02/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QU0200X  Y Ambulatory Health Care FacilitiesClinic/CenterUrgent Care

No ID Information.


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