Provider Demographics
NPI:1992950950
Name:OLD ORCHARD OBSTETRICS&GYNECOLOGY, S.C.
Entity type:Organization
Organization Name:OLD ORCHARD OBSTETRICS&GYNECOLOGY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:847-568-1870
Mailing Address - Street 1:4711 GOLF RD
Mailing Address - Street 2:SUITE 808
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1224
Mailing Address - Country:US
Mailing Address - Phone:847-568-1870
Mailing Address - Fax:847-568-1875
Practice Address - Street 1:4711 GOLF RD
Practice Address - Street 2:SUITE 808
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1224
Practice Address - Country:US
Practice Address - Phone:847-568-1870
Practice Address - Fax:847-568-1875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042616899261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14D0937849OtherCLIA
IL036086420Medicaid
ILF63278Medicare UPIN
IL036086420Medicaid