Fullerton Kimball Medical Group SC

Primary specialty

Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X

Legal business name

FULLERTON KIMBALL MEDICAL GROUP SC

Practice address

3412 W Fullerton Ave
Chicago, IL 60647-2416

Phone

(773) 235-8000

NPI assigned

Mar 16, 2007

Last updated

Aug 24, 2023By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Renlin Xia, MDNPI 1790809960

Title

President

Phone

(773) 235-8000

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in IL

Enrollment records 1

Locations

Practitioners 13

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Michael G Close, M.D.

  • Internal Medicine Physician
  • Chicago, IL
  • NPI 1992893184
  Medicare reassignment Care Compare group NPD
• Heather Rose Cottini, NP-C

  • Family Nurse Practitioner
  • Lombard, IL
  • NPI 1841896644
  Medicare reassignment Care Compare group NPD
• Daniel Ur, M.D.

  • Anesthesiology Physician
  • Chicago, IL
  • NPI 1154364826
  Medicare reassignment Care Compare group NPD
• Andriy Khlopas, NP

  • Nurse Practitioner
  • Chicago, IL
  • NPI 1598263899
  Medicare reassignment Care Compare group
• Renlin Xia, MD

  • Pain Medicine Physician
  • Chicago, IL
  • NPI 1790809960
  Medicare reassignment Authorized official
• Eden Horigan

  • Certified Registered Nurse Anesthetist
  • Lindenhurst, IL
  • NPI 1497725451
  Medicare reassignment NPD
• Stephanie Rancich, DNP, FNP-BC

  • Family Nurse Practitioner
  • Chicago, IL
  • NPI 1528948643
  Medicare reassignment NPD
• Alyson Marie Engle, M.D.

  • Anesthesiology Physician
  • West Palm Beach, FL
  • NPI 1962897272

  IL

  Medicare reassignment NPD
• Ryan John Malcom, MD

  • Surgical Critical Care Physician
  • Valhalla, NY
  • NPI 1992898217

  IL

  Medicare reassignment NPD
• Lyndsey Danielle Deuerling, NP

  • Family Medicine Physician
  • Lombard, IL
  • NPI 1629697297
  Medicare reassignment
• Diana Guillaume, NP

  • Adult Health Nurse Practitioner
  • Skokie, IL
  • NPI 1396037685
  Medicare reassignment
• Ronald Anthony Hickombottom, M.D

  • Internal Medicine Physician
  • Chicago, IL
  • NPI 1023020989
  Medicare reassignment

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1174003200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1692835200000",
    "number": "1831213081",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3412 W FULLERTON AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606472416",
            "telephone_number": "773-235-8000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3412 W FULLERTON AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606472416",
            "telephone_number": "773-235-8000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FULLERTON KIMBALL MEDICAL GROUP SC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-16",
        "last_updated": "2023-08-24",
        "certification_date": "2021-03-22",
        "status": "A",
        "authorized_official_last_name": "XIA",
        "authorized_official_first_name": "RENLIN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "773-235-8000",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": "IL",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS GROUP",
            "identifier": "01635426",
            "state": "IL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036088691   4",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Fullerton Dental Island LLC
• Fullerton Drake Medical Center
• Fullerton Family Dentistry, LTD
• Fullerton Kedzie Professional Pharmacy
• Fullerton Kimball Medical & Surgical Center
• Fullerton Medical Surgical Center
• Fullerton MRI LLC
• Fullerton Occupational Medicine & Immediate Care SC
• Fullerton Rehabilitation Center
• Fullerton Skilled Nursing Facility LLC (Avantara Lincoln Park)

• Multi-Specialty Clinic/Center in Chicago, IL
• Providers in Chicago, IL by specialty
• Multi-Specialty Clinic/Center in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 24, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.