Basic Information
| Provider Information | |||||||||
| NPI: | 1659324788 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TELLEZ MEDICAL CENTER SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 967 | ||||||||
| Address2: | |||||||||
| City: | TINLEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604770967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085326029 | ||||||||
| FaxNumber: | 7084684991 | ||||||||
| Practice Location | |||||||||
| Address1: | 9206 S COMMERCIAL AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606174508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739780707 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 01/22/2019 | ||||||||
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| AuthorizedOfficialLastName: | TELLEZ | ||||||||
| AuthorizedOfficialFirstName: | JUAN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7739780707 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.