Provider Demographics
NPI:1548436892
Name:ASIAN VILLAGE MEDICAL CLINIC PC
Entity type:Organization
Organization Name:ASIAN VILLAGE MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHUONG
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-275-4250
Mailing Address - Street 1:5129 N BROADWAY ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-3018
Mailing Address - Country:US
Mailing Address - Phone:774-275-4250
Mailing Address - Fax:773-275-4263
Practice Address - Street 1:5129 N BROADWAY ST
Practice Address - Street 2:SUITE E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-3018
Practice Address - Country:US
Practice Address - Phone:774-275-4250
Practice Address - Fax:773-275-4263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089675261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL20000433Medicaid
ILC01332Medicare PIN