Organization
S. DAVID DEMOREST
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOSEPH L GIACCHINO JR. MD (ADMINISTRATOR/OWNER)
(708) 343-2500
Entity
Organization
Contact information
Practice address
8383 BELMONT AVENUE, RIVER GROVE, IL 60171
(708) 452-1200
(708) 452-0157
Mailing address
P. O BOX 1624, MELROSE PARK, IL 60160
(708) 452-1200
(708) 425-0157
Taxonomy
Speciality
Code
Description
License number
State
261QP2300X
Primary Care Clinic/Center
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0360677383
—
IL
01
—
737320
MEDICARE
IL
Enumeration date
10/09/2007
Last updated
10/09/2007
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