| Fullerton Kimball Medical Group Sc | |
|
3412 W Fullerton Ave Chicago IL 60647-2416 | |
| (773) 235-8000 | |
| Not Available |
| Full Name | Fullerton Kimball Medical Group Sc |
|---|---|
| Speciality | Clinic/Center |
| Location | 3412 W Fullerton Ave, Chicago, Illinois |
| Authorized Official Name and Position | Renlin Xia (PRESIDENT) |
| Authorized Official Contact | 7732358000 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Fullerton Kimball Medical Group Sc 3412 W Fullerton Ave Chicago IL 60647-2416 Ph: (773) 235-8000 | Fullerton Kimball Medical Group Sc 3412 W Fullerton Ave Chicago IL 60647-2416 Ph: (773) 235-8000 |
| NPI Number | 1831213081 |
|---|---|
| Provider Enumeration Date | 03/16/2007 |
| Last Update Date | 08/24/2023 |
| Medicare PECOS PAC ID | 3476596610 |
|---|---|
| Medicare Enrollment ID | O20050608000406 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1831213081 | NPI | - | NPPES |
| 01635426 | Other | IL | BCBS GROUP |
| 036088691 4 | Medicaid | IL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM1300X | Clinic/center - Multi-specialty | (Illinois) | Primary |
| Provider Name | Daniel Ur |
|---|---|
| Provider Type | Practitioner - Anesthesiology |
| Provider Identifiers | NPI Number: 1154364826 PECOS PAC ID: 8820988272 Enrollment ID: I20040318000723 |
| Provider Name | Renlin Xia |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1790809960 PECOS PAC ID: 2860480456 Enrollment ID: I20040505000249 |
| Provider Name | Tian Xia |
|---|---|
| Provider Type | Practitioner - Anesthesiology |
| Provider Identifiers | NPI Number: 1467492728 PECOS PAC ID: 6901871607 Enrollment ID: I20040827000099 |
| Provider Name | Ronald A Hickombottom |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1023020989 PECOS PAC ID: 8527020171 Enrollment ID: I20041027000542 |
| Provider Name | Cleofe G Casambre |
|---|---|
| Provider Type | Practitioner - Anesthesiology |
| Provider Identifiers | NPI Number: 1730261215 PECOS PAC ID: 7012961204 Enrollment ID: I20050310000406 |
| Provider Name | Michael G Close |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1992893184 PECOS PAC ID: 5698786663 Enrollment ID: I20060505000663 |
| Provider Name | Eden Horigan |
|---|---|
| Provider Type | Practitioner - Certified Registered Nurse Anesthetist (crna) |
| Provider Identifiers | NPI Number: 1497725451 PECOS PAC ID: 1456360049 Enrollment ID: I20070725000138 |
| Provider Name | Ryan J Malcom |
|---|---|
| Provider Type | Practitioner - General Surgery |
| Provider Identifiers | NPI Number: 1992898217 PECOS PAC ID: 3274662689 Enrollment ID: I20100524000498 |
| Provider Name | Diana Guillaume |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1396037685 PECOS PAC ID: 0042532806 Enrollment ID: I20141204002482 |
| Provider Name | Andriy Khlopas |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1598263899 PECOS PAC ID: 7113289398 Enrollment ID: I20180328001310 |
| Provider Name | Alyson M Engle |
|---|---|
| Provider Type | Practitioner - Anesthesiology |
| Provider Identifiers | NPI Number: 1962897272 PECOS PAC ID: 6901191717 Enrollment ID: I20210924002745 |
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