Provider Demographics
NPI:1124134515
Name:CIRCLE FAMILY CARE
Entity type:Organization
Organization Name:CIRCLE FAMILY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:REUBEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETTIFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-379-1000
Mailing Address - Street 1:5002 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644-4127
Mailing Address - Country:US
Mailing Address - Phone:773-379-1000
Mailing Address - Fax:773-379-1342
Practice Address - Street 1:1633 N HAMLIN
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-4607
Practice Address - Country:US
Practice Address - Phone:773-276-1200
Practice Address - Fax:773-276-8285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicaid
IL=========Medicaid