Provider Demographics
NPI:1386976959
Name:BOYCIN MEDICAL CLINIC LTD.
Entity type:Organization
Organization Name:BOYCIN MEDICAL CLINIC LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPERITOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NDUDI
Authorized Official - Middle Name:C
Authorized Official - Last Name:ANIEMEKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-378-4823
Mailing Address - Street 1:5219 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644-4152
Mailing Address - Country:US
Mailing Address - Phone:773-378-4823
Mailing Address - Fax:773-378-9401
Practice Address - Street 1:5219 W MADISON ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-4152
Practice Address - Country:US
Practice Address - Phone:773-378-4823
Practice Address - Fax:773-378-9401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036126142207Q00000X
IL036085291207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085291Medicaid
IL036085291Medicaid
F47244Medicare UPIN