Basic Information
| Provider Information | |||||||||
| NPI: | 1902813595 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH SUBURBAN HEALTH PROFESSIONALS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4250 N MARINE DR | ||||||||
| Address2: | SUITE 236 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606131744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7734040160 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4250 N MARINE DR | ||||||||
| Address2: | SUITE 236 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606131744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7734040160 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 10/15/2007 | ||||||||
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| AuthorizedOfficialLastName: | REYNOLDS | ||||||||
| AuthorizedOfficialFirstName: | ALBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7089224900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.