Basic Information
| Provider Information | |||||||||
| NPI: | 1568489300 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIANS COMMUNITY MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5320 W 159TH ST | ||||||||
| Address2: | STE 400 | ||||||||
| City: | OAK FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604523334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087988112 | ||||||||
| FaxNumber: | 7082240365 | ||||||||
| Practice Location | |||||||||
| Address1: | 5320 W 159TH ST | ||||||||
| Address2: | STE 400 | ||||||||
| City: | OAK FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604523334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087988112 | ||||||||
| FaxNumber: | 7082240365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 06/13/2013 | ||||||||
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| AuthorizedOfficialLastName: | MINGOLELLI | ||||||||
| AuthorizedOfficialFirstName: | GERALD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7085356369 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHYSICIANS COOPERATIVE | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | I | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 042-618622 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 042-618622 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | 042-618622 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208600000X | 042-618622 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207RG0100X | 042-618622 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.