Basic Information
| Provider Information | |||||||||
| NPI: | 1659564292 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FRANKFORT MEDICAL CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1480 MOMENTUM PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606895314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154647212 | ||||||||
| FaxNumber: | 8154647251 | ||||||||
| Practice Location | |||||||||
| Address1: | 10181 W LINCOLN HWY | ||||||||
| Address2: | |||||||||
| City: | FRANKFORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604231274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154647212 | ||||||||
| FaxNumber: | 8154647251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2007 | ||||||||
| LastUpdateDate: | 08/02/2013 | ||||||||
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| AuthorizedOfficialLastName: | TORRES | ||||||||
| AuthorizedOfficialFirstName: | KIAYONA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2197563988 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 036099650 | IL | N | Ambulatory Health Care Facilities | Clinic/Center | 207R00000X | 36099650 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1633069 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 036099650 | 05 | IL | MEDICAID |