Provider Demographics
NPI:1568489300
Name:PHYSICIANS COMMUNITY MEDICAL CENTER
Entity type:Organization
Organization Name:PHYSICIANS COMMUNITY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:MINGOLELLI
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:708-535-6369
Mailing Address - Street 1:5320 W 159TH ST
Mailing Address - Street 2:STE 400
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-3334
Mailing Address - Country:US
Mailing Address - Phone:708-798-8112
Mailing Address - Fax:708-224-0365
Practice Address - Street 1:5320 W 159TH ST
Practice Address - Street 2:STE 400
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-3334
Practice Address - Country:US
Practice Address - Phone:708-798-8112
Practice Address - Fax:708-224-0365
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHYSICIANS COOPERATIVE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-17
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042-618622207Q00000X, 207R00000X, 207RG0100X, 207V00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212861Medicare ID - Type Unspecified